Hipaa Authorization Form (Page 2 of 2) in pdf

Hipaa Authorization Form Page 2

Individual Revocation of PHI Authorization

By completion of this form, I, ____________________________________________ (Member Name),

am notifying ______________________________(Authorized Person’s Name) and the Maine

Municipal Employees Health Trust that I am revoking my authorization dated ___________________ for

the Maine Municipal Employees Health Trust to release my health care information for the purpose of

____________________________________________________________________________________

________________________________________________________(describe purpose of authorization)

I understand that I cannot revoke any action already taken by __________________________________

(Authorized Person’s Name) and the Maine Municipal Employees Health Trust in reliance upon my

authorization prior to the date of this revocation.

Member Signature: _______________________________ Member SS# ____________________ Date:________

Witness Signature: ________________________________ Witness Name: __________________ Date:_______

If the Member listed above is not the covered Employee or Retiree, please complete the following

information:

Employee Name _____________________________

Employee SS# __________________

Please print

* Authorized Person means the individual to whom you grant permission to speak with Health Trust

personnel regarding your claim(s) and/or coverage. An Authorized Person can be a parent, spouse, child,

co-worker, or any other person who may help you with claim and/or coverage issues.

Hipaa Authorization Form Page 2