Get Tx West Texas Medical Associates Patient Portal Proxy Revocation Form 2015-2025

Revoking proxy access to your health information through the TX West Texas Medical Associates Patient Portal is an important process to ensure your privacy. This guide will walk you through the necessary steps to complete the Patient Portal Proxy Revocation Form online, making the process straightforward and efficient.

Follow the steps to complete the revocation form online.

1. Click ‘Get Form’ button to download the form and open it in your document editor.
2. Begin by filling out the patient information section. Enter your full name, including last, first, and middle initial, followed by your sex, street address, city, state, ZIP code, home phone number, work phone number, mobile phone number, and date of birth. Finally, provide the last four digits of your Social Security Number.
3. In the proxy information section, specify the individual whose access you are revoking. Fill out their full name, including last, first, and middle initial, their date of birth, sex, street address, city, state, and ZIP code. Additionally, indicate your relationship to this proxy.
4. After completing the necessary sections, review the patient authorization statement carefully. By signing this section, you are confirming your request to revoke the proxy's access. Ensure that you understand the implications of this action as noted in the statement.
5. Sign and date the form in the designated areas for the patient or their personal representative. If a personal representative is signing, include their name and specify their legal authority to act on your behalf.
6. Once all sections are filled out and reviewed for accuracy, save and download the completed form. You may print it or prepare to share it electronically as needed.
7. Return the completed form to the Health Information Management Department at the specified address, or follow the outlined process for electronic submission if applicable.

Start the process online by completing the TX West Texas Medical Associates Patient Portal Proxy Revocation Form today.