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OTHER NAMES Power of Attorney Revocation Form Healthcare POA Revocation Medical Power of Attorney Revocation

What is a Revocation of Medical Power of Attorney?

A Medical Power of Attorney Revocation Form provides you the means to cancel your previous medical power of attorney (POA) document. If your situation has changed, you may want to cancel your grant of authority. Perhaps you're considering drafting a new document to replace the old one, maybe you need to make substantial revisions and would rather start from scratch, or you could have simply changed your mind. A Revocation of Healthcare Power of Attorney form can help update your important documents to your current needs.

A Medical Power of Attorney grants another individual the authority to make decisions for you in the event you can't make them yourself. If you no longer need this safety net to be in place, you can eliminate the prior grant of power with this document, which is also known as Healthcare Power of Attorney - Revocation. Your needs may change and, if they do, you're well within your rights to update your important documents to reflect those changes. A Medical Power of Attorney Revocation Form can help you update your paperwork to match your changing life.

When to use a Revocation of Medical Power of Attorney:

You want to cancel your previous power of attorney (POA) document.
You plan on making a new power of attorney grant.
You plan on substantially overhauling your previous power of attorney document and would like to start from the beginning.

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REVOCATION OF

I, of , , , hereby revoke my dated . The power and authority granted under the for making healthcare decisions on my behalf is revoked and withdrawn and this document provides notice of such revocation.

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

____________________________________________________

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 principal, that the principal signed or acknowledged this Revocation of Durable Power of Attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud, or undue influence, that I am not the person appointed as attorney-in-fact, and that I am not a treating healthcare provider, an employee of a treating healthcare 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 principal by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law.


Witness Name:


Witness Address:


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Witness Name:	______________________________


Witness Address:	______________________________


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Witness Name:


Witness Address:


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Witness Name:	______________________________


Witness Address:	______________________________


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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 healthcare. 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 healthcare facility.


Witness Signature:	__________________________________________


Witness Name:


Witness Address:


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Witness Name:	______________________________


Witness Address:	______________________________


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Date:	__________________


Witness Signature:	__________________________________________


Witness Name:


Witness Address:


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Witness Name:	______________________________


Witness Address:	______________________________


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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.