Revocation of Authorization to Release Information

Revocation of Authorization to Release Information
You have the right to revoke any Authorization for Release of Health Information.

To do so, you must fill out this form and return it to the Kenneth Young Center (accepted in person or via fax, mail, scanned/emailed).
Name *

First Name Last Name
Date of Birth *
Date of Birth
I wish to revoke my authorization for release of protected health information from the Kenneth Young Center to:
Person or Place Records Should Not Be Disclosed *
Person and/or Place
Date of previously submitted written release being revoked *

Month Day Year
Date
This revocation is given freely and with the understanding that:

· Disclosures made in good faith may have already occurred based on my previously issued authorization and that this revocation cannot apply retroactively to such disclosures.

· I understand that the disclosure of health information may be required by law in certain limited instances despite this revocation.

· The revocation becomes effective once it is received by Kenneth Young Center.

· Records already released by the valid authorization cannot be retracted.

· The facility, its employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the information I previously authorized.
Client's signature *

Clear
Client's printed name *
Date *

Month Day Year
Date
Should be Empty: