Revocation of HIPAA Authorization under HIPAA Rule 164.508

Please correct the errors described below.

Return completed form to Privacy Officer

its employees, or its agents have already acted based on the underlying Authorization.


OFFICE USE ONLY

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.

Loading...