Fill and Sign the Revocation Authorization Form 497334696

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. D ATE :       PATIENT/RESIDENT/CLIENT L AST N AME :       F IRST N AME :       M IDDLE I NITIAL :       A DDRESS       C ITY /S TATE :       Z IP C ODE :       T ELEPHONE N UMBER :       AKA’ S :       SSN:       D ATE OF B IRTH :       INDIVIDUAL OR ORGANIZATION ORIGINALLY AUTHORIZED TO MAKE THE DISCLOSURE: L AST N AME OR E NTITY :       F IRST N AME :       M IDDLE I NITIAL :       A DDRESS       C ITY /S TATE :       Z IP C ODE :       INDIVIDUAL/ORGANIZATION ORIGINALLY AUTHORIZED TO RECEIVE THE INFORMATION: L AST N AME OR E NTITY :       F IRST N AME :       M IDDLE I NITIAL :       A DDRESS       C ITY /S TATE :       Z IP C ODE :       T REATMENT D ATES :       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 S IGNED BY L EGAL R EPRESENTATIVE , R ELATIONSHIP OF I NDIVIDUAL :