Get Revocation Of Authorization Form - Healthscope Benefits

Filling out the Revocation Of Authorization Form - HealthSCOPE Benefits online is a straightforward process that allows users to revoke previously granted authorization for the use and disclosure of protected health information. This guide provides a clear and supportive step-by-step approach to ensure that you complete the form correctly and efficiently.

Follow the steps to effectively complete the form online.

1. Press the ‘Get Form’ button to access the form and open it in your online editor.
2. In Section A, fill in the details of the covered employee requesting the revocation. This includes the employee's name, social security number, employer, current phone number, and the name and social security number of the individual making the request, if different.
3. Provide the current address of the individual making the request. If you have a copy of the original authorization, please attach it. Indicate the date of authorization if known.
4. In Section B, describe the authorization being revoked. Specify the protected health information that was authorized for use and/or disclosure.
5. List the entities that were authorized to use or disclose the protected health information. Provide the names of the individuals or organizations involved.
6. Next, indicate the entities that were authorized to receive and use the protected health information. Again, provide the necessary details.
7. Move to Section C. Here, the individual revoking the authorization must print their name, sign the form, and date it. If a personal representative is signing, they must fill in their details as well.
8. Finally, review the information entered for accuracy. Save your changes, and choose to download, print, or share the completed form as needed.

Complete your documents online today to ensure a smooth and effective revocation process.