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Click ‘Get Form’ to open the HIPAA Revocation document in the editor.
In Section A, enter your name, mailing address, city, state, zip code, phone number, and either your Social Security number or Participant ID as assigned by your program sponsor.
Move to Section B and indicate your revocation of previous authorization for the use and/or disclosure of your protected health information (PHI). Ensure you understand that this revocation will not affect any actions taken before this notice.
If applicable, attach a copy of the previous authorization. Select 'Yes' or 'No' accordingly.
In Section C, if you do not have an attached authorization, provide the date of the original authorization and describe the PHI that was authorized for use or disclosure.
List the entities or persons who were authorized to use or disclose your PHI and those who were authorized to receive it.
Finally, in Section D, print your name, sign the document, and date it. If signed by a personal representative, include their details as well.

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Versions	Form popularity	Fillable & printable
2015	4.8 Satisfied (102 Votes)
2012	4 Satisfied (52 Votes)

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How can I eSign my authorization revocation in Word?

Microsoft Word doesn’t have signing tools to create legitimate eSignatures and enforceable documents. Luckily, DocHub is an online eSignature-compliant editor that supports different file formats, such as .doc files. Log in to your account and upload the Word version of your authorization revocation from your device and cloud, or URL - our editor will automatically turn it into an editable PDF. Make all required alterations in your document and click Sign to create your own legally-binding eSignature. There are four signing methods from which to choose.

How do you edit hipaa authorization revocation form online?

With DocHub, there are several convenient methods to edit your hipaa authorization revocation form online. You can drag and drop the form and modify it straight at the DocHub website or use our browser extension to fill out your form right away. Additionally, you can modify your PDF on your smartphone, as DocHub is compatible with all the accessible mobile platforms.

What does revocation of authorization mean?

The revocation must be submitted in writing, and it only applies to disclosures that havent happened yet. Any information already shared while the authorization was active remains valid. Example: I understand that I may revoke this authorization in writing at any time.

Can HIPAA be revoked?

Answer: A research subject may revoke his/her Authorization at any time. The revocation must be in writing. An oral discussion between the subject and member of the research team does not revoke a HIPAA authorization.