490

A form for revoking an authorization

All Authorizations can be revoked and so a form to do so may come in handy.

(On your letterhead or other identification)

Request to revoke an authorization for disclosure of protected health information

To ______________________________
(clinician or entity)

Re

___________________________

I hereby revoke and cancel the Authorization to Release/Disclose information from the
health care records described below which I made on _____________ to allow you to
send records to __________________________________________________________
_______________________________________________________________________.
The information concerns:
Clients name ____________________________________ Date of birth ____________
Address________________________________________________________________
and these dates:
from _____________________________ to _________________________ and
from _____________________________ to _________________________ and
from _____________________________ to _________________________ .
Other ways of identifying the information of concern: ____________________________
______________________________________________________________________ .
I understand that you may have already made disclosures based on my earlier authorization and so these
disclosures cannot be recovered or undone. I hereby release this clinician/facility from any legal
responsibility or liability for disclosing the information I authorized previously. I also understand that some
disclosures are required by law in some cases and I cannot revoke their release.

________________________________________________

_______________

Signature of client or his or her personal representative

Date

____________________________________________
Printed name of client or personal representative

________________________

Relationship to the client

_______________________________________________________________________
Description of personal representatives authority