Get Wageworks Gen.7004.2 2015-2026

Completing the WageWorks GEN.7004.2 form online is an essential step for revoking authorization for the use and disclosure of your protected health information (PHI). This guide provides detailed instructions to ensure you can navigate the process smoothly.

Follow the steps to accurately complete the WageWorks GEN.7004.2 form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section A, enter your full name in the 'Participant Name' field. Then, provide your mailing address, including city, state, and zip code.
3. Fill in your phone number in the designated field.
4. Provide either your Social Security number or your Participant ID number as assigned by your program sponsor.
5. In Section B, read the statement of revocation carefully. Confirm the revocation of your previous authorization for the use and/or disclosure of your PHI by selecting either 'Yes' or 'No' for the question regarding attachment of a copy of authorization.
6. If you selected 'No', complete Section C by entering the date of the original authorization, the protected health information that was authorized, and the entities or persons authorized to use or disclose that information.
7. In the same section, specify the entities or persons authorized to receive and use your PHI.
8. In Section D, print your name, sign the form, and date it.
9. If a personal representative is signing on your behalf, they must complete their name, signature, date, and relationship to you in the provided fields.
10. After filling out the form, ensure you keep a copy for your records and submit the completed form to WageWorks, Inc. at the provided address or fax number.

Start completing your WageWorks GEN.7004.2 form online today to ensure your revocation is processed efficiently.