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  • Revocation Of Authorization Form - Healthscope Benefits

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Al Requesting Revocation of Authorization Covered Employee's Name: Employee's SSN: - - Covered Employee's Employer: Current Phone: - - Name of Individual Making Request: Individual's SSN: - - Current Address: Copy of authorization attached: Date of authorization (if known): / / Yes No SECTION B: Description of Authorization Revoked Protected Health Information: The revoked authorization had authorized use and/or disclosure of the following protected health informa.

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The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides an individual the right to revoke a previous authorization to disclose protected health information at any time.

The Privacy Rule gives individuals the right to revoke, at any time, an Authorization they have given. The revocation, however, cannot be accepted verbally, but must be in writing. In addition, the written revocation is not effective until the covered entity receives it.

All clients have the opportunity to choose whether or not they want to share their data with other agencies in the community. They do that by completing a Release of Information (ROI) for Data Sharing. Some clients who initially choose to share their data may change their minds later, and choose to revoke their ROI.

A research subject may revoke his/her Authorization at any time. However, a covered entity may continue to use and disclose PHI that was obtained before the individual revoked Authorization to the extent that the entity has taken action in reliance on the Authorization.

Call and write the company. Tell the company that you are taking away your permission for the company to take automatic payments out of your bank account. This is called “revoking authorization.” If you decide to call, be sure to send the letter after you call and keep a copy for your records.

Call and write the company. Tell the company that you are taking away your permission for the company to take automatic payments out of your bank account. This is called “revoking authorization.” If you decide to call, be sure to send the letter after you call and keep a copy for your records.

Answer: A research subject may revoke his/her Authorization at any time. The revocation must be in writing. An oral discussion between the subject and member of the research team does not revoke a HIPAA authorization.

The person has the right to revoke the authorization in writing at any time and a description of how they may revoke. The person's treatment, payment, enrollment or eligibility for benefits is not conditioned on whether they signed the Authorization.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232