(13) EFFECT OF COPY: A copy of this form has the same effect as the original
unless the original has been revoked.
(14) REVOCATION: I understand that I may revoke this OPTIONAL ADVANCE
HEALTH-CARE DIRECTIVE at any time, and that if I revoke it, I should promptly notify my
supervising health-care provider and any health-care institution where I am receiving care and
any others to whom I have given copies of this power of attorney. I understand that I may
revoke the designation of an agent either by a signed writing or by personally informing the
supervising health-care provider.
(15) SIGNATURES: Sign and date the form here:
SIGNATURE OF PERSON GIVING POWER OF ATTORNEY:
____________________________ ____________________________ _________________
Sign your name Print your name Date
Address (Street, City , State, Zip)
It is recommended, but not required, that this form be witnessed.
SIGNATURES OF WITNESSES:
First witness: Second witness:
Sign your name Sign your name
Print your name Print your name
City, State , Zip City, State, Zip