Use This Form If:

• Individuals who have previously designated a Health Care Power of Attorney may find it necessary to revoke that authority if their circumstances change, such as a change in relationships or personal beliefs about medical care. This form allows them to formally notify their health care agent and relevant medical personnel of the revocation.
• Situations requiring the revocation of a Health Care Power of Attorney may arise when the Grantor no longer trusts the appointed agent or wishes to appoint someone new. This form serves as a legal mechanism to ensure that the previous agent's authority is nullified, preventing any potential conflicts in medical decision-making.
• For those who have created a Health Care Power of Attorney but have since decided to manage their own medical decisions or have made alternative arrangements, this form is essential. It provides clear documentation of their intent to revoke previous directives, ensuring that their current wishes are respected by health care providers.
• In cases where the Grantor has passed away and the family needs to clarify that any previously designated Health Care Power of Attorney is no longer valid, this form can help avoid confusion. It serves as a formal notice that the authority granted to the agent is revoked upon the Grantor's death.
• Healthcare professionals may require confirmation that a Health Care Power of Attorney has been revoked to comply with legal standards and ensure that they are acting in accordance with the patient's current wishes. This form provides the necessary documentation to uphold patient autonomy in medical decisions.