Authorization Form For Release Of Protected Health Information Page 2

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RIGH T TO REVOKE AUTH ORIZATION
You have the right to revoke your Authorization for the Release of Protected Health Information. To do so, you must complete
the section below OR send us a written letter revoking your authorization. The revocation should be mailed to:
Resurgens, P.C.
Medical Information Services- Release of Information
5671 Peachtree Dunwoody Road, Suite 700
Atlanta, GA 30342
REVOCATION OF AUTHORIZATION
Patient Name: _______________________________________________________________________________
Date of Birth: ________________________________________________________________________________
Address:
________________________________________________________________________________
_________________________________________________________________________________
I, ____________________________________________, wish to revoke my Authorization for the Release of
Protected Health Information to:_____________________________________________________________________
(Person or place records should not be sent)
I realize that in the event that these records have already been released by valid authorization that the records
cannot be retracted.
Signature of Patient/Legal Representative: _________________________________________ Date: _____________
Printed name (if not signed by the patient): __________________________________________________________
Relationship to Patient: __________________________________________________________________________
A COPY OF THIS COMPLETED, SIGNED AND DATED FORM MUST BE PLACED IN THE PATIENT’S MEDICAL RECORD
Rev. 05/05/2016

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