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Fill and Sign the Revocation of Statutory Power of Attorney for Health Care Texas Form

Fill and Sign the Revocation of Statutory Power of Attorney for Health Care Texas Form

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REVOCATION OF MEDICAL POWER OF ATTORNEY I,       , Declarant, having executed a Medical Power of Attorney on the       day of       , 20       , naming       my attorney-in-fact/agent. The Texas Health and Safety Code, § 166.155, provides that a medical power of attorney may be revoked by written notification to my agent or a licensed or certified health or residential care provider of my intent to revoke said power of attorney. This is my written revocation of the above referenced Power of Attorney and I am providing a copy of it to my attorney-in-fact/Agent. DATED this the       day of       , 20       Signature of Declarant: __________________________________________________________ Printed Name of Declarant:       Address of Declarant:      

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