HIPAA Authorization Revocation form - WageWorks 2026

1. Click ‘Get Form’ to open the HIPAA Authorization Revocation form in the editor.
2. 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.
3. 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.
4. If you have a copy of the previous authorization, check 'Yes' in Section B; otherwise, check 'No'.
5. 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.
6. List the entities or persons who were authorized to use or disclose your PHI as well as those authorized to receive it.
7. 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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