Get Care Everywhere Authorization Revocation Form

The Care Everywhere Authorization Revocation Form allows individuals to revoke previously granted authorizations for the sharing of their health information. This guide provides clear, step-by-step instructions to help you complete this form online, ensuring that your preferences are accurately documented.

Follow the steps to complete the form with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in your name in the designated field clearly, making sure to print it as requested.
3. Enter your date of birth in the appropriate section to help identify your records.
4. Provide your complete address, including street, city, state, and zip code, ensuring all information is correct for processing.
5. Fill in your phone number and email address, as this will facilitate communication regarding your request.
6. Review the statements listed in the form. Initial beside each statement to demonstrate that you acknowledge and understand them.
7. In the section provided, list the names of the organizations for which you are revoking the authorization. Make sure to include all relevant entities.
8. Affirm your understanding that the revocation will prevent any future electronic sharing of your health records with those organizations.
9. Sign the form in the designated area to validate your request and include the date of signing.
10. Once you have filled out all sections, you can save changes, download the completed form, print it for your records, or share it as needed.

Ensure your health information sharing preferences are honored by completing the form online today.