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Revocation of HIPAA Authorization to Release Protected Health Information for Research PurposesPrincipal Investigator name:Title of Study:IRB Study #:Dear Dr., I hereby revoke the Research Subject
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Revocation of HIPAA authorization is a process where an individual decides to terminate their previously granted permission for the use or disclosure of their protected health information.
The individual who originally granted the HIPAA authorization is the one required to file for revocation.
To fill out a revocation of HIPAA authorization, the individual must provide their identifying information, specify the authorization being revoked, and sign the form.
The purpose of revocation of HIPAA authorization is to allow individuals to revoke their previously granted permission for the use or disclosure of their protected health information.
The revocation form typically requires information such as the individual's name, date of birth, specific authorization being revoked, and signature.
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