Fill and Sign the Revocation Authorization Form

REVOCATION OF AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION I hereby REVOKE authorization for use or disclosure of the named individual’s health information as described below. DATE : PATIENT/RESIDENT/CLIENT L AST NAME : F IRST NAME : M IDDLE I NITIAL : ADDRESS C ITY /STATE : Z IP CODE : T ELEPHONE NUMBER : AKA’ S: SSN: D ATE OF BIRTH : INDIVIDUAL OR ORGANIZATION ORIGINALLY AUTHORIZED TO MAKE THE DISCLOSURE: L AST NAME OR ENTITY : F IRST NAME : M IDDLE INITIAL : A DDRESS C ITY /STATE : Z IP CODE : INDIVIDUAL/ORGANIZATION ORIGINALLY AUTHORIZED TO RECEIVE THE INFORMATION: L AST NAME OR ENTITY : F IRST NAME : M IDDLE INITIAL : A DDRESS C ITY /STATE : Z IP CODE : T REATMENT DATES : AUTHORIZATION TO USE OR DISCLOSE THE FOLLOWING INFORMATION IS HEREBY REVOKED: (PLEASE CHECK) History and Physical Examination Discharge Summary Progress Notes Medication Records Interpretation of images: x-rays, sonograms, etc. Laboratory results Dental records Psychiatric records including Consultations HIV/AIDS blood test results; any/all references to those results Physician Orders Pharmacy records Immunization Records Nursing Notes Billing records Drug/Alcohol Rehabilitation Records Complete Record Other (Provide description) ____________________________ Limits of Revocation: I understand that this revocation will not apply to information that has already been released based on the authorization I signed on a prior date. SIGNATURE OF INDIVIDUAL OR LEGAL REPRESENTATIVE S IGNATURE : D ATE : I F SIGNED BY LEGAL REPRESENTATIVE , R ELATIONSHIP OF INDIVIDUAL :