Form OC-140108B "Revocation of Authorization for Release of Protected Health Information" - Oklahoma

What Is Form OC-140108B?

This is a legal form that was released by the Oklahoma Department of Corrections - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2020;
  • The latest edition provided by the Oklahoma Department of Corrections;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form OC-140108B by clicking the link below or browse more documents and templates provided by the Oklahoma Department of Corrections.

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Download Form OC-140108B "Revocation of Authorization for Release of Protected Health Information" - Oklahoma

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OKLAHOMA DEPARTMENT OF CORRECTIONS
Revocation of Authorization for Release of Protected Health Information
You have the right to revoke (end/terminate) your Authorization for Release of Protected Health
Information at any time. To do so, you must complete this form and return it to the Medical
Services Unit. The prior Authorization form(s) will no longer be in effect even if the expiration date
has not been reached.
Statement of Revocation:
I, ____________________________________________ hereby revoke the authorization to
release protected health information for disclosure of my health information records.
 All active authorizations to release my protected health information.
 Specific authorizations to release my protected health information:
Name of authorized recipient: ________________________________________________
Date of authorization
: _______________________________________________
(if known)
Name of authorized recipient: ________________________________________________
Date of authorization
: _______________________________________________
(if known)
Name of authorized recipient: ________________________________________________
Date of authorization
: _______________________________________________
(if known)
Name of authorized recipient: ________________________________________________
Date of authorization
: _______________________________________________
(if known)
I understand in the event that medical information has already been disclosed by a valid
authorization this information cannot be retracted.
The facility and medical staff are hereby released from any legal responsibility or liability for
disclosure of the information I authorized previously.
Inmate Signature: ___________________________________________ Date: ____________
Witness Signature: __________________________________________ Date: ____________
Inmate Name:
DOC #:
(Last, First)
DOC 140108B
(R 8/20)
OKLAHOMA DEPARTMENT OF CORRECTIONS
Revocation of Authorization for Release of Protected Health Information
You have the right to revoke (end/terminate) your Authorization for Release of Protected Health
Information at any time. To do so, you must complete this form and return it to the Medical
Services Unit. The prior Authorization form(s) will no longer be in effect even if the expiration date
has not been reached.
Statement of Revocation:
I, ____________________________________________ hereby revoke the authorization to
release protected health information for disclosure of my health information records.
 All active authorizations to release my protected health information.
 Specific authorizations to release my protected health information:
Name of authorized recipient: ________________________________________________
Date of authorization
: _______________________________________________
(if known)
Name of authorized recipient: ________________________________________________
Date of authorization
: _______________________________________________
(if known)
Name of authorized recipient: ________________________________________________
Date of authorization
: _______________________________________________
(if known)
Name of authorized recipient: ________________________________________________
Date of authorization
: _______________________________________________
(if known)
I understand in the event that medical information has already been disclosed by a valid
authorization this information cannot be retracted.
The facility and medical staff are hereby released from any legal responsibility or liability for
disclosure of the information I authorized previously.
Inmate Signature: ___________________________________________ Date: ____________
Witness Signature: __________________________________________ Date: ____________
Inmate Name:
DOC #:
(Last, First)
DOC 140108B
(R 8/20)