REVOCATION OF AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION

Please correct the errors described below.

I hereby REVOKE authorization for use or disclosure of the named individual’s health information as described below.

Date

PATIENT/RESIDENT/CLIENT

Last Name

First Name

Middle Initial

Address

City/State

Zip Code

Telephone Number

AKAs

SSN

Date of Birth

INDIVIDUAL OR ORGANIZATION ORIGINALLY AUTHORIZED TO MAKE THE DISCLOSURE:

Last Name or Entity

First Name

Middle Initial

Address

City/State

Zip Code

INDIVIDUAL/ORGANIZATION ORIGINALLY AUTHORIZED TO RECEIVE THE INFORMATION:

Last Name or Entity

First Name

Middle Initial

Address

City/State

Zip Code

Treatment Dates

AUTHORIZATION TO USE OR DISCLOSE THE FOLLOWING INFORMATION IS HEREBY REVOKED: (PLEASE CHECK)

History and Physical Examination

Discharge Summary

Progress Notes

Medication Records

Interpretation of images: x-rays, sonograms, etc.

Laboratory results

Dental records

Psychiatric records including Consultations

HIV/AIDS blood test results; any/all references to those results

Physician Orders

Pharmacy records

Immunization Records

Nursing Notes

Billing records

Drug/Alcohol Rehabilitation Records

Complete Record

Other (Provide description)

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.

SIGNATURE OF INDIVIDUAL OR LEGAL REPRESENTATIVE

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.

Signature

Date

If signed by legal representative, relationship of individual.

Your information will be encrypted.

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I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

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