Revocation of Authorization to Release Protected Health Information (PHI)
FLORIDA DEPARTMENT OF ELDER AFFAIRS
4040 Esplanade Way
Tallahassee, Florida 32399
I,
, hereby revoke the authorization for
to use and disclose my
[Name of Individual]
DOEA
protected health information to carry out treatment, payment or health care operations that I
signed on
. __________ However,
may use and disclose my
[Date of Original Authorization]
DOEA
protected health information after I revoke my authorization, if
treated me and I stated on
DOEA
the authorization form that
could use and disclose my protected health information for
DOEA
treatment, payment, or health care operations prior to treatment.
may no longer use or
DOEA
disclose my protected health information without my authorization after
has treated me,
DOEA
obtained payment, and is no longer required to use or disclose my protected health information.
______________________________________
Individual’s Signature and Date
REVOCATION OF AUTHORIZATION TO RELEASE INFORMATION
I,
hereby revoke the authorization to release information I provided to
[Name of Individual]
DOEA
that allowed
to use and disclose my protected health information as I outlined on
DOEA
DOEA's
ization form, which I signed on
for release of my protected health information to
author
[Date]
). I understand that this revocation does not apply to any action
[Name of Person or Facility]
DOEA
has taken in reliance on the authorization I signed earlier. This revocation does not revoke any
and all previous authorizations to release information that I have provided to
.
DOEA
_______________________________________
Individual’s Signature and Date
SPECIAL PROVISIONS
In this section, the individual should outline any special provisions regarding the revocation of the
authorization.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
___________________________________________________________
______________________________________
Individual’s Signature and Date
DOEA Form 187 (04/03)
Page 1 of 1
Revocation of Authorization to Release Protected Health Information (PHI)
FLORIDA DEPARTMENT OF ELDER AFFAIRS
4040 Esplanade Way
Tallahassee, Florida 32399
I,
, hereby revoke the authorization for
to use and disclose my
[Name of Individual]
DOEA
protected health information to carry out treatment, payment or health care operations that I
signed on
. __________ However,
may use and disclose my
[Date of Original Authorization]
DOEA
protected health information after I revoke my authorization, if
treated me and I stated on
DOEA
the authorization form that
could use and disclose my protected health information for
DOEA
treatment, payment, or health care operations prior to treatment.
may no longer use or
DOEA
disclose my protected health information without my authorization after
has treated me,
DOEA
obtained payment, and is no longer required to use or disclose my protected health information.
______________________________________
Individual’s Signature and Date
REVOCATION OF AUTHORIZATION TO RELEASE INFORMATION
I,
hereby revoke the authorization to release information I provided to
[Name of Individual]
DOEA
that allowed
to use and disclose my protected health information as I outlined on
DOEA
DOEA's
ization form, which I signed on
for release of my protected health information to
author
[Date]
). I understand that this revocation does not apply to any action
[Name of Person or Facility]
DOEA
has taken in reliance on the authorization I signed earlier. This revocation does not revoke any
and all previous authorizations to release information that I have provided to
.
DOEA
_______________________________________
Individual’s Signature and Date
SPECIAL PROVISIONS
In this section, the individual should outline any special provisions regarding the revocation of the
authorization.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
___________________________________________________________
______________________________________
Individual’s Signature and Date
DOEA Form 187 (04/03)
Page 1 of 1
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