A Notice form provides legal notification to a party of an important aspect of a legal matter. Failure to provide proper notice is often the cause of delays in the progress of lawsuits and other legal matters. This model form, a Notice of Revocation of Consent to Use land, provides notice of the stated matter. Because each case is unique, you will need to adapt the form to fit your specific facts and circumstances. Available for download now. USLF control number CA-01882
Sample Letter Revoking Consent for Release of Information Keywords: Consent, Release of Information, Revocation, Sample Letter 1. Introduction: In this sample letter revoking consent for release of information, we aim to provide a detailed template for individuals who wish to withdraw their previously granted consent for the release of any personal information. It is important to remember that such letters should be customized according to your specific situation. Below, you will find a general structure and key points to include when preparing a letter to revoke consent for the release of personal information. 2. Types of Sample Letters Revoking Consent for Release of Information: a. Medical Release of Information: Use this type of letter to revoke consent previously provided to healthcare providers or medical institutions to release your medical records to third parties. b. Employment Release of Information: If you have authorized your employer or former employer to disclose your employment records, salary details, or other related information to external parties, you can use this letter to revoke that consent. c. Educational Release of Information: Educational institutions may require your consent to disclose information such as academic records or disciplinary actions to certain individuals or organizations. Use this letter to withdraw that consent. d. Financial Release of Information: If you have given consent for financial institutions or credit bureaus to share your financial information, you can use this letter to revoke that consent. 3. Sample Letter Template: [Your Name] [Your Address] [City, State, ZIP] [Email Address] [Phone Number] [Date] [Recipient's Name] [Recipient's Position/Designation] [Name of the Institution/Organization] [Institution Address] [City, State, ZIP] Dear [Recipient's Name], Subject: Revocation of Consent for Release of Information I am writing to formally revoke my consent for the release of any personal information, as previously granted to [institution/organization name], effective immediately. I kindly request that [institution/organization name] cease any further dissemination or disclosure of my personal information to any third party or entity. [Specify the reason(s) for revoking the consent (optional). For example, if there have been recent changes in your circumstances or privacy concerns, elaborate on those here.] Please consider this letter as an official notice of my revocation of consent, in accordance with relevant laws and regulations pertaining to the release of personal information. I expect full compliance with this request and ask that you confirm the successful revocation of my consent within [specify a reasonable time frame, e.g., 14 days] from the date of receipt of this letter. To ensure a seamless process, I request a written confirmation of the receipt of this letter with details regarding the actions taken to implement the revocation, such as the date of the revocation, the parties informed, and any steps taken to retrieve or delete my personal information from your records. Should any legal consequences arise due to non-compliance with this request, I reserve my right to protect my privacy and pursue appropriate legal remedies available. Please address any correspondence or confirmation regarding this revocation of consent to the following address: [Your Preferred Correspondence Address] [City, State, ZIP] Thank you for your immediate attention to this matter. I trust that [institution/organization] will respect my decision and act accordingly. Sincerely, [Your Name] 4. Conclusion: With this sample letter revoking consent for the release of information, individuals can easily prepare a detailed and formal request to withdraw their previously granted consent. Remember, personalizing the letter to your specific situation and keeping a polite and professional tone are essential when composing such letters.
