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Fill and Sign the Revocation of Advance Health Care Directive Four Parts Hawaii Form

Fill and Sign the Revocation of Advance Health Care Directive Four Parts Hawaii Form

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REVOCATION OF ADVANCE HEALTH-CARE DIRECTIVE I, ___________________________________________________________________, Declarant, having executed An Advance Health Care Directive on the ________ day of ________________________, 20____. Hawaii Revised Statutes §327E-4 provides that this Directive may be revoked by me at any time by the following means: (a) An individual may revoke the designation of an agent only by a signed writing or by personally informing the supervising health-care provider. (b) An individual may revoke all or part of an advance health-care directive, other than the designation of an agent, at any time and in any manner that communicates an intent to revoke. This is my written revocation of the above referenced Directive and I am providing a copy of this revocation to all parties to whom I provided a copy of the original Directive. DATED this the _________ day of ______________________________, 20____. Signature of Declarant: __________________________________________________________ Printed Name of Declarant: _______________________________________________________ Address of Declarant: ___________________________________________________________

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