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.

PATIENT/RESIDENT/CLIENT

INDIVIDUAL OR ORGANIZATION ORIGINALLY AUTHORIZED TO MAKE THE DISCLOSURE:

INDIVIDUAL/ORGANIZATION ORIGINALLY AUTHORIZED TO RECEIVE THE INFORMATION:

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

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.

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