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Get Revoking Hipaa Authorization Form

Uses or disclosures of your individually identifiable health information, please complete Section II of this form. Date: Name: Address 1: Address 2: UserID: Telephone: City, State: Zip Code: Section I Revoking an Authorization This section applies to authorizations that you have sent to FSAFEDS, which allow FSAFEDS to disclose your information to another person or entity (such as an attorney). You may revoke an authorization by checking the appropriate item below, signing this section, a.

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