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Fill and Sign the Revocation of Statutory Living Will Louisiana Form

Fill and Sign the Revocation of Statutory Living Will Louisiana Form

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REVOCATION OF DECLARATION (Living Will) (Louisiana Revised Statutes 40:1299.58.4) I, ___________________________________________________________________, Declarant, executed a Declaration (Living Will) on the ________ day of ________________________, 20____. Louisiana Revised Statutes 40:1299.58.4 provides that my Declaration (Living Will) can be revoked by me at any time by any of the following methods: (1) By being cancelled, defaced, obliterated, burned, torn, or otherwise destroyed by the declarant or by some person in the presence of and at the direction of the declarant. (2)(a) By a written revocation of the declarant expressing the intent to revoke, signed and dated by the declarant. (b) The attending physician shall record in the patient's medical record the time and date when notification of the written revocation was received. (3)(a) By an oral or nonverbal expression by the declarant of the intent to revoke the declaration. This is my written revocation of my Declaration (Living Will) and is provided to all persons to whom I have provided a copy of my Declaration. DATED this the _________ day of ______________________________, 20____. Signature of Declarant: __________________________________________________________ Printed Name of Declarant: _______________________________________________________ Address of Declarant: ___________________________________________________________

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