Get Hipaa Authorization Revocation Form - Wageworks

Filling out the HIPAA Authorization Revocation Form is an important step in managing your protected health information. This guide aims to provide clear and supportive instructions to help you complete the form easily and efficiently online.

Follow the steps to fill out the form accurately

1. Press the ‘Get Form’ button to access and open the HIPAA Authorization Revocation Form in your online editor.
2. In Section A, enter your participant name, mailing address, city, state, and zip code. Provide your telephone number and either your Social Security number or the participant ID assigned to you by WageWorks.
3. Proceed to Section B where you will state your revocation. Indicate that you revoke your previous authorization for the use or disclosure of your protected health information (PHI). Acknowledge that this revocation will not impact actions taken based on your previous authorization before receipt of this notice. If you have a copy of the previous authorization, select 'Yes' or 'No' accordingly.
4. In Section C, provide details of the authorization you are revoking if your previous authorization is not attached. Include the date of the authorization if known, the type of protected health information (PHI) involved, and the entities or persons who were authorized to use or disclose this information. Also, specify the entities or persons authorized to receive and use this PHI.
5. In Section D, print your name, sign the form, and date it. If a personal representative is signing on your behalf, ensure they fill in their name, provide their signature, date it, and explain their relationship to you.
6. After signing, make sure to keep a copy of the completed authorization revocation for your records before submitting it.
7. Lastly, submit the form by mailing it to WageWorks, Inc., Claims Administrator, PO Box 14053, Lexington, KY 40512, or by faxing it to (866) 672-3703.

Complete your documents online now for efficient processing!