Use This Form If:

• Individuals who have previously designated someone to make health care decisions on their behalf may decide to revoke that authority if their circumstances change. For example, if the relationship with the designated agent deteriorates or if the individual wishes to appoint a different agent, this form is essential to formally communicate the revocation.
• Situations requiring a change in health care representation often arise when a person’s health condition improves or deteriorates. In such cases, the original power of attorney may no longer reflect the individual's wishes, necessitating the use of this revocation form to ensure that their current preferences are respected.
• To comply with legal requirements, it is crucial for individuals to formally revoke a Health Care Power of Attorney when they no longer wish for the designated agent to make medical decisions. This ensures that any medical providers are aware of the updated authority and can act accordingly in emergencies.
• For those who have moved to a different state or have undergone significant life changes, revoking a previous Health Care Power of Attorney can help align their medical decision-making preferences with their current situation. This form serves to clarify their intentions and prevent any confusion regarding their health care directives.
• In cases where the original agent designated in the Health Care Power of Attorney is no longer able or willing to fulfill that role, the Grantor must revoke the existing document. This form provides a clear legal basis for the change, ensuring that the individual's health care wishes are accurately represented.