Revocation of Release of Information

SECTION A: INDIVIDUAL REVOKING THE AUTHORIZATION

This section is used to identify the individual who is the subject of the information, usually yourself. (If you are a parent, you may also revoke any authorization you made for the release of health information for your minor child.)

First Name(Required)

Last Name(Required)

Last 4 digits of Social Security Number(Required)

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone

Email

SECTION B: INDIVIDUAL’S STATEMENT OF REVOCATION

I revoke my authorization for the use and/or disclosure of the protected health information described in Section C below. If available, a copy of the original authorization should be attached. I understand that this revocation will not affect any action Radiology Ltd., PLC, RLC, LLC, or others took in reliance on my previous authorization and before receipt of this written revocation.

Do you have a copy of the original Release of Information form?(Required)

If yes, you will be asked to upload it. If you do not have a copy, you will need to answer some questions so that we may best assist you.

Yes

No

Upload original release of information(Required)

Drop files here or

Accepted file types: jpg, jpeg, pdf, doc, docx, xlsx, xls, Max. file size: 8 MB.

If you are having any difficulties with this form, please call us at 1 (833) 642-BHWC (2492) or (907) 729-BHWC (2492) for assistance.

SECTION C: DESCRIPTION OF AUTHORIZATION REVOKED

Must be completed if previous Release of Information form is not uploaded

Date of authorization (if known):

This Revocation of Authorization applies to the following protected health information:

Specific description of information to be revoked:(Required)

This would be the information you authorized to be released. Examples: “All information necessary to coordinate treatment and payment for my health care needs,” or “All claims and benefit information for treatment at clinic in February YYYY.”

Person/Organizations authorized to provide the information:(Required)

This could be a provider, clinic, hospital and/or health insurance company. Examples: “ABC Health Plan,”

Person/Organizations authorized to receive the information:(Required)

Please provide the full name (or other means to identify) of the person or business you want to revoke authorization to receive the information you authorized for release. Examples: “Jane Doe, spouse,” or “ABC Health insurance”.

SECTION D: INDIVIDUAL’S SIGNATURE

To be valid, this Revocation of Authorization must be signed by the person listed in Section A. Parents may sign this Revocation of Authorization if it relates to the release of health information on their minor child(ren). If you are signing this form in the capacity of the patient’s personal representative, such as a parent, guardian or power of attorney, you must also include your name and relationship to the person listed in Section A.

If this Revocation of Authorization is being signed by a personal representative on behalf of the individual, please complete the following:

Personal Representative’s Name:

Relationship to Individual:

I have had full opportunity to read and consider the contents of this Revocation of Authorization.

Patient Name(Required)