I may cancel this authorization to the extent allowed by law. If I do, I understand that the doctor or practice may have already released information about me after I gave permission. I know canceling this authorization would not prohibit any release of information by the doctor or practice relying on my original authorization.
There are two ways to cancel this agreement:
Sign and date a form available from the Doctor or Practice called “Revocation of Authorization for Use and Disclosure
of Health Care Information.”
Write a letter to the Doctor or Practice. If I write a letter, it must say that I want to cancel my authorization to disclose
my Health Care Information. I (or my authorized representative) must sign and date the letter.
Once my doctor gives out the information I want to release, I know that my doctor has no control over the information. The individual or organization that I authorized to receive the information might re-disclose it. Federal or state privacy laws may no longer protect the information.
Please acknowledge by signing below.