Hipaa Revocation Of Authorization Form Page 2

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to receive the information you authorized for release. Examples: “Clara Smith, wife,” or “XYZ
Auto Insurance”.
SECTION D: Individual’s signature
To be valid, this Revocation of Authorization must be signed and dated by the person listed in
Section A. Parents may sign this Revocation of Authorization if it relates to the release of
health information on their minor child(ren). If you are signing this form in the capacity of the
patient’s personal representative, such as a parent, guardian or power of attorney, you must
also include your name and relationship to the person listed in Section A.
I, ______________________________________________, have had full opportunity to read
and consider the contents of this Revocation of Authorization.
Signature:
Date:
If this Revocation of Authorization is being signed by a personal representative on behalf of
the individual, please complete the following:
Personal Representative’s Name:
Relationship to Individual:
AFTER YOU HAVE SIGNED THE REVOCATION OF AUTHORIZATION, KEEP A COPY FOR
YOUR RECORDS and send to Janet F. Rosales R.H.I.T., Privacy/Security Officer, Radiology Ltd., 677
N. Wilmot Rd., Tucson, AZ. 85711 or via email
janet.rosales@rad
If you have questions about completing this form, contact us our Security/ Privacy
Officer at 520.545.1798

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