Use This Form If:

• Individuals who have previously designated a Health Care Power of Attorney may find it necessary to revoke that authority due to changes in personal circumstances, such as a change in relationships or health status. This form allows them to formally notify relevant parties of the revocation.
• Situations requiring the revocation of a Health Care Power of Attorney can arise when the appointed agent is no longer deemed suitable or trustworthy. By using this form, the Grantor can ensure that their medical decisions will be handled by someone else who aligns with their current wishes.
• For those who have created a new Health Care Power of Attorney, it is essential to revoke any prior documents to avoid confusion regarding medical decision-making. This form serves as a clear notification that the previous authority is no longer valid.
• In instances where the Grantor has decided to take control of their own health care decisions and no longer wishes to delegate that authority, this revocation form is necessary. It provides a legal basis for the Grantor to assert their autonomy in medical matters.
• Healthcare providers may require confirmation that a previously appointed Health Care Power of Attorney has been revoked before proceeding with treatment decisions. This form provides the necessary documentation to ensure that the patient's current wishes are respected.