Request to Revoke Authorization to Use and Disclose Protected Health Information


Center for Family Development

1258 High Street, Eugene, OR 97401 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: 8e358bce97f50666563cd1628605d69a90cc4288
Timestamp Audit
August 6, 2020 1:01 pm PSTRequest to Revoke Authorization to Use and Disclose Protected Health Information Uploaded by Jason Dooley - jdooley@c-f-d.org IP 65.157.96.202
August 6, 2020 3:22 pm PSTCFD 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