Fill and Sign the Revocation of Health Care Proxy Michigan Form

REVOCATION OF DESIGNATION OF PATIENT ADVOCATE (Michigan Consolidated Laws, 700.5510) I,       , Declarant, executed a Designation of Patient Advocate on the       day of       , 20       , regarding my decisions and choices concerning my health care. Pursuant to the Michigan Consolidated Laws, 700.5510, which provides that a Designation of Patient Advocate may be revoked by a Patient at any time and in any manner by which he or she is able to communicate an intent to revoke the designation, I hereby revoke all or those parts of that Designation of Patient Advocate as indicated below: [       ] All of the Designation of Patient Advocate. [       ] Part 1: Designation of Patient Advocate. [       ] 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 Designation of Patient Advocate and is provided to all persons to whom I have provided a copy of my Designation of Patient Advocate. DATED this the       day of       , 20       . Signature of Declarant: __________________________________________________________ Printed Name of Declarant:       Address of Declarant: