Use This Form If:

• Individuals who have previously designated someone as their Health Care Agent may find it necessary to revoke that designation due to a change in personal circumstances, such as a falling out with the agent or a change in health care preferences. This form allows them to formally notify all relevant parties of the revocation.
• Situations requiring the revocation of a Health Care Power of Attorney may arise when the Grantor wishes to appoint a new agent or when the original agent is no longer able or willing to serve. By using this form, the Grantor can ensure that their current wishes are clearly communicated and legally recognized.
• For those who have created a Health Care Power of Attorney but later decide to take control of their health care decisions themselves, this revocation form provides a clear and legally binding method to rescind the previous authority granted to another individual.
• In cases where the Grantor has experienced a significant life event, such as a divorce or the death of a previously designated agent, they may need to revoke their existing Health Care Power of Attorney. This form serves as an official record of their decision and helps prevent any confusion regarding their health care preferences.
• Healthcare professionals may require confirmation that a Health Care Power of Attorney has been revoked before proceeding with treatment decisions. The use of this form ensures that medical providers have the most current and accurate information regarding the patient's wishes.