Use This Form If:

• Individuals who have previously designated someone to make health care decisions on their behalf may find it necessary to revoke that authority if their circumstances change. For instance, if the relationship with the appointed agent deteriorates or if the individual wishes to appoint someone else, this form serves to officially communicate the revocation.
• Situations requiring a change in health care representation often arise due to changes in personal circumstances, such as divorce or the death of the original agent. In such cases, using the Health Care Power of Attorney Revocation ensures that the individual’s current wishes are clearly documented and legally recognized.
• To comply with state laws, a person may need to formally revoke a Health Care Power of Attorney to prevent any potential conflicts regarding medical decisions. This form provides the necessary legal documentation to ensure that health care providers are aware of the revocation and can act accordingly.
• For those who have reconsidered their health care decisions, perhaps after receiving new medical information, this form allows them to withdraw their previous consent. This ensures that their health care preferences are accurately reflected and respected moving forward.
• Families may encounter situations where a loved one has lost capacity and a previously appointed agent is no longer suitable. In such instances, revoking the prior Health Care Power of Attorney is essential to appoint a more appropriate decision-maker.