Health Care Power of Attorney Revocation

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Form is used to give notice that a previously granted Health Care Power of Attorney has been revoked.

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If the Grantor of a Health Care Power of Attorney decides to revoke the document, it is almost always required that the revocation be in writing. The Health Care Power of Attorney Revocation is used to give notice by the Grantor that a previously granted Health Care Power of Attorney (sometimes referred to as a Living Will or Health Care Directive) has been revoked.

This package includes (1) Checklist & Instructions for Health Care Power of Attorney Revocation (2) Information about Health Care Power of Attorney Revocation (3) Health Care Power of Attorney Revocation.
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.











Health Care Power of Attorney Revocation







This Packet Includes:
1. General Instructions & Checklist
2. Information
3. Health Care Power of Attorney Revocation









General Instructions & Checklist
 Health Care Power of Attorney Revocation




    The Principal (i.e. the person granting the Health Care Power of Attorney Revocation; sometimes called the Grantor) should sign the Health Care Power of Attorney Revocation before a Notary even if it is not required.  Notarization will also help to ensure that the revocation is effective and support its authenticity if challenged. Notarization is also necessary to record the revocation.  

    This revocation becomes effective immediately.

   The original or a copy of the revocation must be given to the Agent (i.e. Attorney-in-Fact) to show that it was the Grantors intent to revoke the Power of Attorney.  If possible, the Principal should keep a copy of any document showing that the Agent received the original revocation (i.e. certified mail receipt, delivery receipt etc..).

    Any health care providers need to be given a copy of the Revocation as well and copies of the revocation should be kept in any relevant medical files.

    Although not always required, it is always a good idea to also have two witnesses sign the Revocation of Power of Attorney. The witnesses should be adults. Generally, anyone related by blood or marriage to the Principal, the Agent or the Notary should not be a witness.

    The Principal should keep a copy of the revocation in his/her files. Copies of the revocation should be sent to anyone who may have received a copy of the original Power of Attorney or who may have dealt with the Agent acting on behalf of the Principal. It is a good idea to keep a record of anyone who was sent a copy of the revocation. In the event the original power of attorney was filed publicly (i.e. recorded), then the notice of revocation should also be filed publicly, in the same manner.



    The Principal should destroy any copies of the Health Care Power of Attorney so as to avoid any questions about the revocation or  its effectiveness.  



    The exact full title of the document(s) that you are revoking should be inserted in the revocation document. If more than one document is being revoked, then each document needs to be identified i.e. if you are revoking a Health Care Power of Attorney and a Living Will, be sure to identify both.



    These forms are not intended and are not a substitute for legal advice. Laws are different from state to state and may change from time to time. These forms should only be a starting point for you and should not be used without consulting with an attorney first.

    The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com







Information
Health Care Power of Attorney Revocation




If the Grantor of a Health Care Power of Attorney decides to revoke the document, it is almost always required that the revocation be in writing. The Health Care Power of Attorney Revocation is used by the Grantor to give notice that a previously granted Health Care Power of Attorney (sometimes referred to as a Living Will or Health Care Directive) has been revoked.

This revocation becomes effective immediately.

Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general information that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions.








DISCLAIMER:

FindLegalForms, Inc. (“FLF”) is not a law firm and does not provide legal advice.  The use of these materials is not a substitute for legal advice. Only an attorney can provide legal advice.  An attorney should be consulted for all serious legal matters.  No Attorney-Client relationship is created by use of these materials.  

THESE MATERIALS ARE PROVIDED “AS-IS.  FLF DOES NOT GIVE ANY EXPRESS OR IMPLIED WARRANTIES OF MERCHANTABILITY, SUITABILITY OR COMPLETENESS FOR ANY OF THE MATERIALS FOR YOUR PARTICULAR NEEDS.  THE MATERIALS ARE USED AT YOUR OWN RISK.  IN NO EVENT WILL:  I) FLF, ITS AGENTS, PARTNERS, OR AFFILIATES; OR II) THE PROVIDERS, AUTHORS OR PUBLISHERS OF ITS MATERIALS, BE RESPONSIBLE OR LIABLE FOR ANY DIRECT, INDIRECT, INCIDENTAL, SPECIAL, EXEMPLARY, OR CONSEQUENTIAL DAMAGES (INCLUDING, BUT NOT LIMITED TO, PROCUREMENT OF SUBSTITUTE GOODS OR SERVICES; LOSS OF USE, DATE OR PROFITS; OR BUSINESS INTERRUPTION) HOWEVER USED AND ON ANY THEORY OF LIABILITY, WHETHER IN CONTRACT, STRICT LIABILITY, OR TORT (INCLUDING NEGLIGENCE OR OTHERWISE) ARISING IN ANY WAY OUT OF THE USE OF THESE MATERIALS. 


Health Care Power of Attorney Revocation

I, ___________________________________  (Principal)  maintaining an address at __________________________________________________ (address of Principal), hereby revoke my __________________________________________________  (title of document(s)) dated __________________ and all power and authority granted thereby including powers for making health care decisions on my behalf and concerning artificial life sustaining procedures is revoked and withdrawn and this document provides notice of such revocation.

IN WITNESS WHEREOF, I have signed this Health Care Power of Attorney Revocation
on ___________________ (date).

_____________________________
Principal


Witness Signature:__________________
Date: ___________________________
Name: ___________________________
City: _________________________
State:_________________________


Witness Signature:__________________
Date: ___________________________
Name: ___________________________
City: _________________________
State:_________________________

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


Notary Acknowledgment

State of __________________________    )
                        )   ss
County of ________________________    )

On __________ before me, ______________________________________________________ (here insert name and title of the officer), personally appeared _____________________________
_______________________________________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
WITNESS my hand and official seal.
Signature __________________________________ (Seal)


Number of Pages3
DimensionsDesigned for Letter Size (8.5" x 11")
EditableYes (.doc, .wpd and .rtf)
UsageUnlimited number of prints
Product number#17171
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.











Health Care Power of Attorney Revocation







This Packet Includes:
1. General Instructions & Checklist
2. Information
3. Health Care Power of Attorney Revocation









General Instructions & Checklist
 Health Care Power of Attorney Revocation




    The Principal (i.e. the person granting the Health Care Power of Attorney Revocation; sometimes called the Grantor) should sign the Health Care Power of Attorney Revocation before a Notary even if it is not required.  Notarization will also help to ensure that the revocation is effective and support its authenticity if challenged. Notarization is also necessary to record the revocation.  

    This revocation becomes effective immediately.

   The original or a copy of the revocation must be given to the Agent (i.e. Attorney-in-Fact) to show that it was the Grantors intent to revoke the Power of Attorney.  If possible, the Principal should keep a copy of any document showing that the Agent received the original revocation (i.e. certified mail receipt, delivery receipt etc..).

    Any health care providers need to be given a copy of the Revocation as well and copies of the revocation should be kept in any relevant medical files.

    Although not always required, it is always a good idea to also have two witnesses sign the Revocation of Power of Attorney. The witnesses should be adults. Generally, anyone related by blood or marriage to the Principal, the Agent or the Notary should not be a witness.

    The Principal should keep a copy of the revocation in his/her files. Copies of the revocation should be sent to anyone who may have received a copy of the original Power of Attorney or who may have dealt with the Agent acting on behalf of the Principal. It is a good idea to keep a record of anyone who was sent a copy of the revocation. In the event the original power of attorney was filed publicly (i.e. recorded), then the notice of revocation should also be filed publicly, in the same manner.



    The Principal should destroy any copies of the Health Care Power of Attorney so as to avoid any questions about the revocation or  its effectiveness.  



    The exact full title of the document(s) that you are revoking should be inserted in the revocation document. If more than one document is being revoked, then each document needs to be identified i.e. if you are revoking a Health Care Power of Attorney and a Living Will, be sure to identify both.



    These forms are not intended and are not a substitute for legal advice. Laws are different from state to state and may change from time to time. These forms should only be a starting point for you and should not be used without consulting with an attorney first.

    The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com







Information
Health Care Power of Attorney Revocation




If the Grantor of a Health Care Power of Attorney decides to revoke the document, it is almost always required that the revocation be in writing. The Health Care Power of Attorney Revocation is used by the Grantor to give notice that a previously granted Health Care Power of Attorney (sometimes referred to as a Living Will or Health Care Directive) has been revoked.

This revocation becomes effective immediately.

Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general information that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions.








DISCLAIMER:

FindLegalForms, Inc. (“FLF”) is not a law firm and does not provide legal advice.  The use of these materials is not a substitute for legal advice. Only an attorney can provide legal advice.  An attorney should be consulted for all serious legal matters.  No Attorney-Client relationship is created by use of these materials.  

THESE MATERIALS ARE PROVIDED “AS-IS.  FLF DOES NOT GIVE ANY EXPRESS OR IMPLIED WARRANTIES OF MERCHANTABILITY, SUITABILITY OR COMPLETENESS FOR ANY OF THE MATERIALS FOR YOUR PARTICULAR NEEDS.  THE MATERIALS ARE USED AT YOUR OWN RISK.  IN NO EVENT WILL:  I) FLF, ITS AGENTS, PARTNERS, OR AFFILIATES; OR II) THE PROVIDERS, AUTHORS OR PUBLISHERS OF ITS MATERIALS, BE RESPONSIBLE OR LIABLE FOR ANY DIRECT, INDIRECT, INCIDENTAL, SPECIAL, EXEMPLARY, OR CONSEQUENTIAL DAMAGES (INCLUDING, BUT NOT LIMITED TO, PROCUREMENT OF SUBSTITUTE GOODS OR SERVICES; LOSS OF USE, DATE OR PROFITS; OR BUSINESS INTERRUPTION) HOWEVER USED AND ON ANY THEORY OF LIABILITY, WHETHER IN CONTRACT, STRICT LIABILITY, OR TORT (INCLUDING NEGLIGENCE OR OTHERWISE) ARISING IN ANY WAY OUT OF THE USE OF THESE MATERIALS. 


Health Care Power of Attorney Revocation

I, ___________________________________  (Principal)  maintaining an address at __________________________________________________ (address of Principal), hereby revoke my __________________________________________________  (title of document(s)) dated __________________ and all power and authority granted thereby including powers for making health care decisions on my behalf and concerning artificial life sustaining procedures is revoked and withdrawn and this document provides notice of such revocation.

IN WITNESS WHEREOF, I have signed this Health Care Power of Attorney Revocation
on ___________________ (date).

_____________________________
Principal


Witness Signature:__________________
Date: ___________________________
Name: ___________________________
City: _________________________
State:_________________________


Witness Signature:__________________
Date: ___________________________
Name: ___________________________
City: _________________________
State:_________________________

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


Notary Acknowledgment

State of __________________________    )
                        )   ss
County of ________________________    )

On __________ before me, ______________________________________________________ (here insert name and title of the officer), personally appeared _____________________________
_______________________________________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
WITNESS my hand and official seal.
Signature __________________________________ (Seal)


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