HIPAA Authorization Revocation form - WageWorks: Fill out & sign online

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Click ‘Get Form’ to open the HIPAA Authorization Revocation form in the editor.
In Section A, enter your Participant Name, Mailing Address, City, State, Zip Code, Telephone number, and either your Social Security Number or Participant ID assigned by WageWorks.
Move to Section B and indicate your revocation of previous authorization for the use and/or disclosure of your protected health information (PHI). Confirm that you understand this revocation will not affect any actions taken before this notice.
If you have a copy of the previous authorization, check 'Yes' in Section B; otherwise, check 'No'.
In Section C, if no authorization is attached, provide the date of the revoked authorization (if known) 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 as well as those authorized to receive it.
Finally, in Section D, print your name, sign the form, and date it. If applicable, include details for a personal representative.

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How to revoke an authorization form?

1) Call and write the company. Tell the company that you are taking away your permission for the company to take automatic payments out of your bank account. This is called revoking authorization. If you decide to call, be sure to send the letter after you call and keep a copy for your records.

Should I decline the HIPAA authorization form?

If you do not have sufficient information to make an informed decision, you should always decline a HIPAA authorization request. The HIPAA Privacy Rule stipulates that Protected Health Information (PHI) can only be used or disclosed by covered entities and business associates for required or permitted purposes.

Can a patient revoke their authorization to release PHI?

The Health Insurance Portability and Accountability Act of 1996 (HIPAA)1 Privacy Rule2 requires covered entities3 to allow individuals4 to request that the covered entities restrict the use and disclosure of their protected health information (PHI) for treatment, payment, or health care operations.

How to revoke authorization?

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.

How do I revoke a HIPAA authorization?

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.