Revocation of Authorization to Disclose Health Information

Revocation of Authorization to Disclose Health Information
Use this form to formally revoke your prior authorization for the disclosure of your health information.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Name of Person or Organization Previously Authorized to Receive Your Health Information
Date of Original Authorization
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Description of Health Information Previously Authorized for Disclosure
Effective Date of Revocation
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Revocation (optional)
Signature
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Date of Signature
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: