Request to Revoke Authorization to Use and Disclose Protected Health Information


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:

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.


Leave this empty:

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Signature Certificate
Document name: Request to Revoke Authorization to Use and Disclose Protected Health Information
lock iconUnique Document ID: cb575357707c3f0247be9d2cac58651fd2b734d0
Timestamp Audit
August 6, 2020 1:01 pm PDTRequest to Revoke Authorization to Use and Disclose Protected Health Information Uploaded by Do Not Reply - donotreply@c-f-d.org IP 65.157.96.202
August 6, 2020 3:22 pm PDTCFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129
March 18, 2021 2:51 pm PDT Document owner jdooley@c-f-d.org has handed over this document to donotreply@c-f-d.org 2021-03-18 14:51:26 - 65.157.96.202
March 18, 2021 2:51 pm PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202
May 3, 2021 9:27 am PDTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202