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Fill and Sign the Revocation of Health Care Proxy Massachusetts Form

Fill and Sign the Revocation of Health Care Proxy Massachusetts Form

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REVOCATION OF HEALTH CARE PROXY I,       , Declarant, executed a Health Care Proxy on the       day of       , 20       , regarding my decisions and choices concerning my health care. Pursuant to the General Laws of Massachusetts, Chapter 201D: Section 7, which provides that a Health Care Proxy may be revoked at any time by a principal by the Principal's notifying the agent or a health care provider orally or in writing or by any other act evidencing a specific intent to revoke the proxy, I hereby revoke all or those parts of that Health Care Proxy as indicated below: [       ] All of the Health Care Proxy. [       ] Part 1: Designation of Agent for Health Care. [       ] Part 2: Instructions for Health Care. [       ] Part 3: Anatomical Gifts at Death. [       ] Part 4: Primary Physician This is my written revocation as indicated above of my Health Care Proxy and is provided to all persons to whom I have provided a copy of my Health Care Proxy. DATED this the       day of       , 20       . Signature of Declarant: __________________________________________________________ Printed Name of Declarant:       Address of Declarant:      

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