I hereby REVOKE authorization for use or disclosure of the named individual’s health information as described below.
Limits of Revocation: I understand that this revocation will not apply to information that has already been released based on the authorization I signed on a prior date.
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.