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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 Privacy Rule gives individuals the right to revoke, at any time, an Authorization they have given. By completing this form you are requesting a restriction to any further disclosures of your personal health information. Note: Any covered participant over the age of 18 requires a separate Authorization Form to be completed. Purpose: This form is used to revoke or to confirm revocation of a previously authorized disclosure. All requests for revocation of an individual's authorization to access, release, use, or disclose PHI must be submitted to the HIPAA Privacy Officer in writing. The purpose of this webform is to revoke your prior authorization for Color to disclose health information. Previously, you completed an Authorization for the Release of Protected Health Information (PHI) Form allowing Blue Cross and. I revoke any authorizations I have previously given to the Plan to disclose my protected health information to the following Person or Entity.