This required section states that the person who made an Advance Health Directive (the "Declarant") now intends to rescind or cancel ("revoke") it. Press [Ctrl+F1] for more information.
This required section contains the signature block for the Declarant. Press [Ctrl+F1] for more information.
This optional section provides the witness signature block. If a state requires witnesses, this block will be automatically included. Press [Ctrl+F1] for more information.
This required section lists persons or institutions given a copy of the revocation. It will not be effective until the health care provider or agent has been informed of the revocation. Press [Ctrl+F1] for more information.
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Revocation of Advance Health Care Directive
REVADD
The Revocation of Advance Health Care Directive is a document under which a person revokes an Advance Health Care Directive by declaring that the document will no longer be effective.
Enter the Declarant's city or edit the information as desired.
Enter the state where the Declarant currently resides. The Declarant's selected state will control some of the language in the document. If the Declarant is unsure what state to enter, an Attorney should be consulted. Press [Ctrl+F1] for more information.
Enter the name of the Declarant or edit the information as desired. Use the P.I. Manager to select and paste a record.
Enter the title of the Advance Health Care Directive as it appears in the document that will be revoked. For example, "Medical Directive" or "Advance Health Care Directive". The title of this revocation will be centered when previewed or printed. Press [Ctrl+F1] for more information.
RAD01
! Revocation Section (1 of 4)
[This document has some state specific portions. Enter the state where the Declarant currently resides: !.]
REVOCATION OF
[NAME AS IT APPEARS ON THE DOCUMENT]
I, ! of
!, ! !,
! Country: !,
! SSN: !,
hereby revoke my ! dated !. The power and authority granted to my physician or any health care provider
! and health care agent
is revoked and withdrawn and this document provides notice of such revocation.
Enter the state where the Declarant currently resides. The Declarant's selected state will control some of the language in the document. If the Declarant is unsure what state to enter, an Attorney should be consulted. Press [Ctrl+F1] for more information.
Enter the title of the Advance Health Care Directive as it appears in the document that will be revoked. For example, "Medical Directive" or "Advance Health Care Directive". The title of this revocation will be centered when previewed or printed. Press [Ctrl+F1] for more information.
Enter the name of the Declarant or edit the information as desired. Use the P.I. Manager to select and paste a record.
Enter the Declarant's street address or edit the information as desired.
Enter the Declarant's extended street address or edit the information as desired.
Enter the Declarant's city or edit the information as desired.
Enter the Declarant's zip/postal code or edit the information as desired.
Enter an X to include the Declarant's country, if outside the United States.
Enter the country or edit the information as desired.
Enter an X to include the Declarant's social security number. Many health care facilities file their records, including Advance Health Care Directives, by the Declarant's social security number.
Enter the Declarant's social security number or edit the information as desired.
Using the format MM/DD/YYYY, enter the Advance Directive's date. This date is the date the Advance Directive was signed, and should be the same date that is shown on the Advance Directive.
Enter an X if the Advance Directive designated a health care agent to make health care decisions for the Declarant if the Declarant is unable to do so.
RAD02
! Signature Section (2 of 4)
Dated this _____ day of _______________, 19___, at
!, !.
________________________________________
Enter the city in which the revocation will be signed or edit the information as desired.
Enter the state in which the revocation will be signed or edit the information as desired.
RAD03
! Optional Witness Signature Section (3 of 4)
! [Mississippi]
I hereby witness this revocation and attest that:
(1) I personally know the maker of this revocation and believe the maker of this revocation to be of sound mind;
(2) To the best of my knowledge, at the time of the execution of this revocation, I:
(a) Am not related to the maker of this revocation by blood or marriage;
(b) Do not have any claim on the estate of the maker of this revocation;
(c) Am not entitled to any portion of the estate of the maker of this revocation by any will or by operation of law; and
(d) Am not a physician attending the maker of the revocation or a person employed by a physician attending the maker of this revocation.
! [New Hampshire]
I am not the Declarant's spouse or heir at the time of witnessing this document.
! [New Mexico]
We declare that we have attained the age of majority and that the Declarant signed and executed the instrument as his/her Revocation of ! and that he/she signed willingly, or directed another to sign for him/her, and that he/she executed it as his/her free and voluntary act for the purposes expressed; and that each of the witnesses saw the Declarant sign or another sign for him/her at his/her direction and, in the presence of the Declarant and in the presence of each other, signed the Revocation of ! as witness and that to the best of his/her knowledge the Declarant had reached the age of majority, was of sound mind and was under no constraint or undue influence.
! [Vermont]
I am not the Declarant's spouse nor related to the Declarant by blood or adoption at the time of witnessing this document.
! [Wyoming]
I declare under penalty of perjury under the laws of Wyoming that the person who signed or acknowledged this document is personally known to me to be the Declarant, that the Declarant signed or acknowledged this Revocation of ! in my presence, that the Declarant appears to be of sound mind and under no duress, fraud, or undue influence, that I am not the person appointed as health care agent (attorney-in-fact), and that I am not a treating health care provider, an employee of a treating health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility, nor an employee of an operator of a residential care facility. I further declare under penalty of perjury under the laws of Wyoming that I am not related to the Declarant by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of the Declarant upon the death of the Declarant under a will now existing or by operation of law.
! [All other states - there is no additional text required other than the Witness signatures.]
This is an optional section in most states. This box is checked if your state requires witnesses. If your state does not require witnesses, but you wish to include witness signatures, enter an X in this box.
Mississippi requires that two "disinterested" persons, witness the signature of the revocation. Note the limitations on who may serve as witnesses. The program selects this option if the Declarant resides in Mississippi. Press [Enter] to continue to the next state.
New Hampshire requires that two "disinterested" persons, witness the signature of the revocation. Note the limitations on who may serve as witnesses. The program selects this option if the Declarant resides in New Hampshire. Press [Enter] to continue to the next state.
New Mexico requires at least one witness sign this revocation. Note the limitations on who may serve as witnesses. The program selects this option if the Declarant resides in New Mexico. Press [Enter] to continue to the next state.
Vermont requires two "disinterested" persons witness the signature of the revocation. Note the limitations on who may serve as witnesses. The program selects this option if the Declarant resides in Vermont. Press [Enter] to continue to the next state.
Wyoming requires that at least one "disinterested" person witness the revocation. Note the limitations on who may serve as witnesses. Press [Enter] to continue to the next field.
There is no additional text required for your state. The program selects this option if the Declarant does not reside in New Hampshire, New Mexico, Mississippi, Vermont or Wyoming. Press [Enter] to move to the first witness field.
Enter the name of the FIRST Witness or use the P.I. Manager to select and paste a record. A witness formalizes the document even if not required by your state. The following information regarding the name and address of the Witness may be left blank and be completed when the document is signed.
Enter the Witness' street address or edit the information as desired.
Enter the Witness' extended street address or edit the information as desired.
Enter the Witness' city or edit the information as desired.
Enter the Witness' state/province or edit the information as desired.
Enter the Witness' zip/postal code or edit the information as desired.
Enter an X to include the Witness' country, if outside the United States.
Enter the country or edit the information as desired.
Enter the name of the SECOND Witness or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the Witness may be left blank and be completed when the document is signed.
Mississippi
New Hampshire
New Mexico
Vermont
Wyoming
Mississippi
New Hampshire
New Mexico
Vermont
Wyoming
RAD04
! Notification Section (4 of 4)
[Copies of this revocation should be given to anyone who has a copy of your Advance Directive. Generally, the revocation will not be effective until your physician or other health care provider has been provided a copy of the revocation. The revocation should be recorded in your medical chart if you are a patient in a health care institution.]
Names of institutions/individuals who have been provided a copy of this revocation:
! - !
! - !
! - !
! - !
! - !
! - !
! - !
NOTE: This revocation should be filed with the Mississippi Bureau of Vital Statistics of the State Board of Health.
Enter the name of a person or institution who has been given a copy of the revocation or use the P.I. Manager to select and paste a record. If you are a patient in a health care institution a copy of the revocation should be placed in your medical chart.
Enter an X to include the name of another person or institution who has been given a copy of the revocation.
Enter the name of another person or institution who has been given a copy of the revocation or use the P.I. Manager to select and paste a record.
This special note applies to the state of Mississippi only. The program includes this sentence if you indicated that the Declarant resides in Mississippi.
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