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How to fill out the REVOCATION OF PREVIOUS AUTHORIZATION - Dartmouth-Hitchcock online
Filling out the Revocation of Previous Authorization form is an important step in managing your healthcare information. This guide will provide you with clear instructions to ensure the process is smooth and straightforward.
Follow the steps to complete your revocation form online.
- Click ‘Get Form’ button to access the form and open it in the editor.
- Enter your patient name in the designated field. This section identifies you as the person revoking access.
- Provide your date of birth in the specified area. This helps to verify your identity.
- Fill in your telephone number. This information may be used for any necessary follow-up regarding your request.
- List the name(s) of the physician(s) or organization(s) from whom you are revoking authorization for access to your electronic record.
- Include the address of the physician(s) or organization(s) mentioned. This ensures that the request is clear and directed appropriately.
- Clearly state your intention to revoke permission by checking any required options if applicable or drafting a brief statement.
- Sign the form in the designated area as a formal confirmation of your request to revoke authorization.
- Date your signature to indicate when the revocation request was made.
- After ensuring all fields are completed, save your changes. You may download or print the form for your records.
- Return the completed form to the Release of Information Section at the specified address listed at the top of the form.
Complete your revocation documents online today for better management of your medical records.
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