Revocation of Advance Directive - Pennsylvania

Pennsylvania · Fillable PDF · Free

Use this form to cancel all or part of a health care power of attorney, living will, or mental health advance directive. A written, notarized revocation leaves a clear record for hospitals and family. Use this form to cancel all or part of a health care power of attorney, living will, or mental health advance directive.

Serving Pennsylvania. Appointments require a Pennsylvania-commissioned notary.

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Who this form is for

• Use this form to cancel all or part of a health care power of attorney, living will, or mental health advance directive. A written, notarized revocation leaves a clear record for hospitals and family.

What you'll need

• The original Revocation of Advance Directive - Pennsylvania packet and its instructions.
• The names, dates and supporting records identified in this packet.
• Acceptable identification if a notarial act is requested; arrange any required qualified witnesses.

How to complete it

1. Check what you are revoking List each document and its date. You may revoke all or only part.
2. List who gets a copy Your doctors, hospital, former agent and family.
3. Sign it, with a witness and notary if possible Bring a current photo ID.
4. Tell your doctor A revocation takes effect when your physician or provider is told about it.

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These forms are a free convenience, not legal advice. First Choice Mobile Notary & Apostille is not a law firm. Consult an attorney licensed in the relevant state for legal questions.

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