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OTHER NAMES Advance Directive Revocation Medical Directive Revocation Living Will Revocation

What is an Advance Health Care Directive - Revocation?

You used to be sure about certain things if you were ever terminally ill or unconscious. But you've changed your mind and could use an Advanced Health Care Directive Revocation. Hey, things change. Medical advancements are made. Just make sure you take care of that with our Advance Health Directive Revocation. 
 
Nobody knows what will happen tomorrow. If you're getting cold feet about serious health decisions, you might need an Advance Health Care Directive Revocation. Well, permanent isn't always a black and white word in medicine. Or maybe you're just having second thoughts. But you were sure enough a few years ago that you signed an Advance Health Care Directive. That's okay. You can always change your wishes. Getting an Advance Health Care Directive Revocation nixes any old documents and lets you start over.

When to use an Advance Healthcare Directive Revocation:

  • You want to revoke an existing Advance Directive.
  • You want to revoke an existing Advance Directive prior to executing a new Advance Directive.

Sample Advance Health Care Directive - Revocation

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REVOCATION OF

 

 

I, of , , , hereby revoke my dated . The power and authority granted to my physician or any health care provider is revoked and withdrawn and this document provides notice of such revocation.

 

Dated this _____ day of _______________, _____, at , .

 

 

 

________________________________________

I hereby witness this revocation and attest that:

(1) I personally know the maker of this revocation and believe the maker of this revocation to be of sound mind;

(2) To the best of my knowledge, at the time of the execution of this revocation, I:

(a) Am not related to the maker of this revocation by blood or marriage;

(b) Do not have any claim on the estate of the maker of this revocation;

(c) Am not entitled to any portion of the estate of the maker of this revocation by any will or by operation of law; and

(d) Am not a physician attending the maker of the revocation or a person employed by a physician attending the maker of this revocation.

 

I am not the Declarant's spouse or heir at the time of witnessing this document.

 

We declare that we have attained the age of majority and that the Declarant signed and executed the instrument as his/her Revocation of and that he/she signed willingly, or directed another to sign for him/her, and that he/she executed it as his/her free and voluntary act for the purposes expressed; and that each of the witnesses saw the Declarant sign or another sign for him/her at his/her direction and, in the presence of the Declarant and in the presence of each other, signed the Revocation of as witness and that to the best of his/her knowledge the Declarant had reached the age of majority, was of sound mind and was under no constraint or undue influence.

 

I am not the Declarant's spouse nor related to the Declarant by blood or adoption at the time of witnessing this document.

 

I declare under penalty of perjury under the laws of Wyoming that the person who signed or acknowledged this document is personally known to me to be the Declarant, that the Declarant signed or acknowledged this Revocation of in my presence, that the Declarant appears to be of sound mind and under no duress, fraud, or undue influence, that I am not the health care agent (attorney-in-fact) of Declarant, and that I am not a treating health care provider, an employee of a treating health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility, nor an employee of an operator of a residential care facility. I further declare under penalty of perjury under the laws of Wyoming that I am not related to the Declarant by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of the Declarant upon the death of the Declarant under a will now existing or by operation of law.

 

 

Witness Name:

Witness Address:

  ,

Witness Name: _________________________

Witness Address: _________________________

  _________________________

  _________________________

Witness Name:

Witness Address:

  ,

Witness Name: _________________________

Witness Address: _________________________

  _________________________

  _________________________

STATEMENT OF WITNESSES

 

I declare that who signed or acknowledged this document (the "Principal") has identified himself or herself to me, that signed or acknowledged this document in my presence, that appears to be of sound mind and under no duress or undue influence. I am at least 18 years of age and not the Agent of , related to by blood, marriage, or adoption, entitled to any portion of the estate of under a will or codicil or intestate succession laws or directly financially responsible for 's health care. I am not a provider of health or residential care, an employee of a provider of health or residential care, the operator of community care facility, or an employee of an operator of a health care facility.

 

 

 

Witness Signature: __________________________________________

 

Witness Name:

Witness Address:

  ,

Witness Name: ______________________________

Witness Address: ______________________________

  ______________________________

  ______________________________

 

Date: __________________

 

 

Witness Signature: __________________________________________

 

Witness Name:

Witness Address:

  ,

Witness Name: ______________________________

Witness Address: ______________________________

  ______________________________

  ______________________________

 

Date: __________________

 

STATE OF KANSAS

COUNTY OF ____________________

 

This instrument was acknowledged before me on _____ day of ____________________, _____, by .

 

 

 

________________________________________

Notary Public

 

(Seal, if any)

 

My appointment expires: _________________________

 

Names of institutions/individuals who have been provided a copy of this revocation:

 

_____ You should sign this document in the presence of two disinterested witnesses who sign the document in your presence and in each other's presence.

_____ You should sign this document in the presence of a notary who then notarizes the document.

_____ Even though witnesses may not be technically required, the use of a witness formalizes the document and provides added assurance that the Revocation will be recognized.

_____ The Revocation should be filed with the Mississippi Bureau of Vital Statistics of the State Board of Health.

 

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