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Request to Revoke Authorization to Use and Disclose Protected Health Information

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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.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

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August 6, 2020 1:01 pm PDT

Request 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 PDT

CFD 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 PDT

CFD 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 PDT

CFD 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