Hipaa Revocation Of Authorization Form printable pdf download

Hipaa Revocation Of Authorization Form

Radiology Ltd P.L.C., & RLC, LLC

HIPAA REVOCATION OF AUTHORIZATION FORM

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.)

Name:

Social Security Number:

Address:

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

attached.

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

revocation.

Copy of authorization attached:



Yes



No (complete section C.)

SECTION C: Description of authorization revoked (complete if authorization not

attached)

Date of authorization (if known):

____/____/____

This Revocation of Authorization applies to the following protected health

information:

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

Hipaa Revocation Of Authorization Form

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