Revocation of Patient Advocate Designation - Michigan

Download Revocation of Patient Advocate Designation - Michigan PDF

Michigan · Fillable PDF · Free

Use this form to cancel a Michigan Patient Advocate Designation, a living will, or other written health care instructions you signed earlier. Use this form to cancel a Michigan Patient Advocate Designation, a living will, or other written health care instructions you signed earlier.

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Who this form is for

Use this form to cancel a Michigan Patient Advocate Designation, a living will, or other written health care instructions you signed earlier.

What you'll need

Read the packet and check the receiving agency's required form.
Gather the names, dates and supporting records requested in the document.
Review the packet's signing, identification and witness instructions.

How to complete it

Identify the documents (Page 1) Check each document you are revoking and enter its date and agent names.
Sign before a notary (Page 2) Under MCL 700.5510, you may revoke a patient advocate designation at any time and in any manner that communicates your intent. A notarized revocation gives clear proof of the date and your identity. Bring a current, government-issued photo ID.
Notify your doctors and agents (Page 2) Give copies to your doctor, hospital, and each agent named, and record each notice.
Ask them to destroy or return their copies of the revoked documents.
To give new instructions, sign a new Michigan Patient Advocate Designation. We have a free form. Ask your doctors to note the revocation in your medical record.

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