Revocation of Authorization to Disclose Medical Information (HIPAA)

This Revocation of HIPAA Authorization letter allows patients to formally withdraw prior permission granted to a person, provider, attorney, or third-party organization to access their protected health information (PHI). It is ideal when care transitions, legal representation ends, or privacy concerns arise.

Key features include:

• Names the party whose access is being revoked

• Clearly states the revocation applies to all future disclosures

• Requests provider confirmation and update to patient records

• Cites rights under HIPAA and California law

• Editable Microsoft Word format for fast use

Essential for maintaining control over who can access your medical data and ensuring your privacy preferences are up to date.