Fill and Sign the End of Life Planningwisconsin Department of Health Services Form

REVOCATION OF DECLARATION TO PHYSICIANS (WISCONSIN LIVING WILL)(Wisconsin Statutes 154.05) I, ___________________________________________________________________, Declarant, executed a Declaration to Physicians (Living Will) on the ________ day of ________________________, 20____. Wisconsin Statutes 154.05 provides that a Living Will can be revoked by me at any time by any of the following methods: 154.05(1)(a) (a) By being canceled, defaced, obliterated, burned, torn or otherwise destroyed by the declarant or by some person who is directed by the declarant and who acts in the presence of the declarant. 154.05(1)(b) (b) By a written revocation of the declarant expressing the intent to revoke, signed and dated by the declarant. 154.05(1)(c) (c) By a verbal expression by the declarant of his or her intent to revoke the declaration. This revocation becomes effective only if the declarant or a person who is acting on behalf of the declarant notifies the attending physician of the revocation. 154.05(1)(d) (d) By executing a subsequent declaration. This is my written revocation of my Living Will and is provided to all persons to whom I have provided a copy of my Living Will. DATED this the _________ day of ______________________________, 20____. Signature of Declarant: __________________________________________________________ Printed Name of Declarant: _______________________________________________________ Address of Declarant: ___________________________________________________________