Sample letter revoking consent 2026

1. Click ‘Get Form’ to open the sample letter revoking consent in the editor.
2. In Section A, enter your name, mailing address, city, state, zip code, telephone number, and either your Social Security number or Participant ID number as assigned by WageWorks.
3. Move to Section B and clearly state your intention to revoke authorization. Check 'Yes' or 'No' regarding whether a copy of the previous authorization is attached.
4. If you did not attach a copy of the authorization, complete Section C by providing the date of authorization (if known) and detailing the protected health information that was previously authorized for use or disclosure.
5. List the entities or persons who were authorized to use or disclose your PHI in Section C. Then specify those authorized to receive and use this information.
6. In Section D, print your name, sign the document, and date it. If applicable, provide details for a personal representative who may be signing on your behalf.
7. Finally, ensure you keep a copy for your records before submitting it to WageWorks at the provided address or fax number.

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