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California Problem Gambling Treatment Services Program Request to Revoke Consent Please complete and sign this form to revoke or cancel a consent provided to the CPG TSP. Telephone Monitoring and
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How to fill out request to revoke consent

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How to fill out request to revoke consent:

01
Start by addressing the request to the appropriate organization or individual. Include their name, title, and contact information.
02
Clearly state the purpose of the request, which is to revoke your previous consent. Be specific about the consent you are revoking, mentioning any specific agreements or documents related to the consent.
03
Provide your personal information, including your full name, contact details, and any identification numbers or reference numbers relevant to the consent.
04
Explain your reasons for revoking your consent. It can be helpful to provide any supporting evidence or documentation that strengthens your case.
05
Specify the effective date of the revocation. This is when you want the revocation to take effect.
06
Sign the request and include the date of submission.
07
Keep a copy of the request for your records.

Who needs a request to revoke consent?

01
Individuals who have previously given their consent to a particular organization or individual.
02
Individuals who no longer wish to allow the use of their personal information or any other form of consent.
03
People who want to have more control over their personal data and limit its usage by entities they have previously granted consent to.
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Request to revoke consent is a formal request to withdraw previously given consent for a specific action or use of personal information.
Any individual who has previously given consent for the use of their personal information and wishes to withdraw that consent is required to file a request to revoke consent.
To fill out a request to revoke consent, the individual must clearly state their intention to withdraw consent and provide any necessary information or documentation as required by the organization.
The purpose of a request to revoke consent is to allow individuals to have control over their personal information and to stop any further use or processing of that information.
The request to revoke consent should include relevant personal information such as name, contact details, and any reference numbers associated with the original consent.
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