Get Tx Arise Austin Medical Center Revocation Of Authorization For Release Of Protected Health 2014-2025

Understanding how to revoke authorization for the release of your protected health information is essential for controlling your personal data. This guide provides a clear and supportive step-by-step approach to filling out the TX Arise Austin Medical Center Revocation of Authorization form online.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to access the revocation form and open it in the online editor.
2. In the first field, enter the date of the original authorization you are revoking. This helps clarify which authorization is being canceled.
3. Provide your printed name in the designated area to confirm your identity as the patient.
4. Enter your date of birth in the specified field to further verify your identity.
5. Include your social security number in the appropriate section. This is used for identification purposes and is important for accurate processing.
6. Add your Medical Record Number (MRN), which is crucial for the medical center to locate your records.
7. List the dates of service during which your protected health information was disclosed. This will provide context to the revocation.
8. Sign in the space provided to officially revoke your authorization. If you are signing on behalf of someone else, ensure the representative's name and relationship to the patient is included.
9. Date your signature in the next field to indicate when the revocation is being executed.
10. If applicable, provide the printed name and relationship of the representative to the patient in the specified fields.
11. Once you have completed all required fields, save your changes, and choose to download, print, or share the form as needed.

Take control of your health information and complete your revocation form online today.