1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Request to Revoke Authorization to Use and Disclose Protected Health Information

Date of Request:

(Name of individual on record to whom Authorization to Use and                         (Date of Birth)                                      Disclose Protected Health Information form pertains)

I request the Authorization to Use and Disclose Protected Health Information previously signed for the following entity be revoked:

Authorized Agency or Individual Name:  

I understand this will be effective, except to the extent that action has been taken prior to revoking it. If I want to authorize communication to be re-instated with this agency or individual in the future, I will need to complete a new Authorization to Use and Disclose Protected Health Information.

My signature affirms that I have read and understand this form and have had the opportunity to ask questions.

This document is being signed by: ClientPersonal Representative, see below

If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.

Full legal name of Personal Representative:

Relationship to client:

Definition of Personal Representative:
For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.
For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.