Revocation of HIPAA Authorization under HIPAA Rule 164.508 2026

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The document is a formal revocation of HIPAA Authorization, allowing a patient to withdraw consent for their health information to be shared with a healthcare provider. It includes sections for the patient's details, the healthcare provider's information, and signatures from both the patient and a witness. The revocation takes effect upon receipt unless actions have already been taken based on the original authorization.

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Send hipaa privacy authorization via email, link, or fax. You can also download it, export it or print it out.

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Click ‘Get Form’ to open the Revocation of HIPAA Authorization in our editor.
Begin by entering the name of the patient in the designated field, ensuring accuracy for proper identification.
Next, input the name of the health care provider involved in the original authorization. This is crucial for clarity.
Fill in the date of the original authorization to establish a clear timeline regarding your revocation.
Indicate whether any actions have been taken based on the original authorization by specifying if applicable.
Sign and print your name at the bottom of the form, along with today's date to validate your revocation.
Have a witness sign and print their name as required, ensuring compliance with legal standards.
Finally, return the completed form to your Privacy Officer at the specified address for processing.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Can a HIPAA authorization be revoked?

Yes. The Privacy Rule gives individuals the right to revoke, at any time, an Authorization they have given.

What is the HIPAA statute?

At a glance. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 establishes federal standards protecting sensitive health information from disclosure without patients consent. The US Department of Health and Human Services issued the HIPAA Privacy Rule to implement HIPAA requirements.

What is the HIPAA authorization rule?

Authorization. A covered entity must obtain the individuals written authorization for any use or disclosure of protected health information that is not for treatment, payment or health care operations or otherwise permitted or required by the Privacy Rule.

What is the HIPAA authorization statute?

If a covered entity seeks an authorization from an individual for a use or disclosure of protected health information, the covered entity must provide the individual with a copy of the signed authorization.

What happens if you decline HIPAA authorization?

If you decline a HIPAA authorization request, the consequences depend on the purpose of the request. Generally, covered entities are not allowed to condition the provision of treatment, payment, enrollment in a health plan, or your eligibility for benefits on a HIPAA authorization. However, there are a few exceptions.

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What must an authorization be under HIPAA?

All authorizations must be in plain language, and contain specific information regarding the information to be disclosed or used, the person(s) disclosing and receiving the information, expiration, right to revoke in writing, and other data.