Hipaa Revocation Of Authorization Form


Radiology Ltd P.L.C., & RLC, LLC
Purpose: This form is used to revoke or to confirm revocation of a previously authorized
disclosure. You may make this revocation at any time by giving written notice to a Privacy
Contact listed on our Notice of Privacy Practices. You may only revoke an authorization you
made for yourself or your minor child.
This revocation of authorization will not affect any
action we took in reliance on the initial authorization prior to receiving this notice.
SECTION A: Individual revoking the authorization
This section is used to identify the individual who is the subject of the information, usually
yourself. (If you are a parent, you may also revoke any authorization you made for the release
of health information for your minor child.)
Social Security Number:
Date of Birth:
Telephone Number:
E-Mail Address:
SECTION B: Individual’s statement of revocation
I revoke my authorization for the use and/or disclosure of the protected health information
described in Section C below. If available, a copy of the original authorization should be
I understand that this revocation will not affect any action Radiology Ltd., PLC, RLC, LLC, or
others took in reliance on my previous authorization and before receipt of this written
Copy of authorization attached:
No (complete section C.)
SECTION C: Description of authorization revoked (complete if authorization not
Date of authorization (if known):
This Revocation of Authorization applies to the following protected health
Specific description of information to be revoked. (This would be the information you
authorized to be released. Examples: “All information necessary to coordinate treatment and
payment for my health care needs,” or “All claims and benefit information for my hospital
stay in February YYYY.”)
Person/Organizations authorized to provide the information. This could be a provider,
clinic, hospital and/or health insurance company. Examples: “City of Portland Health Plan,”
Person/Organizations authorized to receive the information. Please provide the full
name (or other means to identify) of the person or business you want to revoke authorization


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