Healthcare Withdrawal Document

HEALTHCARE WITHDRAWAL DOCUMENT

Patient Information

Date of Birth:    Gender:

Authorization Being Withdrawn

I hereby withdraw the authorization or consent previously given as described below. Check all items that apply:

Release of medical records to a third party
Consent to a specific treatment or procedure
Participation in research or clinical trial
Electronic health record access or portal sharing
Other (describe below)

Effect and Scope of Withdrawal

Revocation: I revoke the authorization or consent identified above to the fullest extent permitted by applicable law. This revocation is intended to stop any further disclosures or uses of my protected health information or to terminate consent to treatment as indicated, except where limited by law.

Exceptions and Limitations: I understand and acknowledge that this revocation will not affect disclosures or actions that have already been made in good faith by the holder of the original authorization prior to the date that the holder receives this signed withdrawal. This revocation will not affect information that is required to be retained by law or to the extent that a third party has a right to rely on disclosures made pursuant to the original authorization.

Consequences of Withdrawal: I understand that withdrawing consent to treatment or to disclosure of certain information may affect my ability to participate in programs or to receive certain services. I further understand that my healthcare provider may need to continue to use or disclose health information as permitted or required by law for treatment, payment, or healthcare operations.

Directives to Provider: I direct the provider or custodian of my records named below to cease further disclosure of my protected health information to the recipients identified above, except as required by law or where the recipient has already acted in reliance on the prior authorization.

Desired Effective Date of Withdrawal (if other than upon receipt):

Acknowledgments and Certifications

By signing below, I certify that I am the patient identified above or am the patient's duly authorized personal representative. I certify that I understand the meaning and effect of this withdrawal and that I have the authority to make this request. I understand that any person who acts in good faith prior to receipt of this withdrawal may continue to rely on the original authorization.

I request confirmation that my revocation has been processed. Please send confirmation by (check preferred method):

Mail    Fax    Email    In person

Privacy Notice Acknowledgment: I acknowledge that I have received or been offered the healthcare provider's notice of privacy practices and understand my rights regarding use and disclosure of my health information.

Optional Additional Information

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