Fill and Sign the Revocation Health Care Directive Form

REVOCATION OF HEALTH CARE DIRECTIVE (Minnesota Statutes 145C.09) I, ___________________________________________________________________, Declarant, executed a Health Care Directive on the ________ day of ________________________, 20____, regarding my decisions and choices concerning my health care. Pursuant to the Minnesota Statutes 145C.09, which provides that a Health Care Directive may be revoked by (1) canceling, defacing, obliterating, burning, tearing, or otherwise destroying the health care directive instrument or directing another in the presence of the principal to destroy the health care directive instrument, with the intent to revoke the health care directive in whole or in part; (2) executing a statement, in writing and dated, expressing the principal's intent to revoke the health care directive in whole or in part; (3) verbally expressing the principal's intent to revoke the health care directive in whole or in part in the presence of two witnesses who do not have to be present at the same time; or (4) executing a subsequent health care directive, to the extent the subsequent instrument is inconsistent with any prior instrument. I hereby revoke all or those parts of that Designation of Patient Advocate as indicated below: [ ] All of the Health Care Directive. [ ] Part 1: Appointment of Health Care Agent. [ ] Part 2: Instructions for Health Care. This is my written revocation as indicated above of my Health Care Directive and is provided to all persons to whom I have provided a copy of my Health Care Directive. DATED this the _________ day of ______________________________, 20____. Signature of Declarant: __________________________________________________________ Printed Name of Declarant: _______________________________________________________ Address of Declarant: ___________________________________________________________