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AUTHORIZATION TO DISCLOSE BILLING RECORDS La Hacienda Treatment Center, P.O. Box 1, Hunt, TX 78024, Phone: (800) 7496160, Fax: (830) 2386119 Please read this entire form before signing and complete

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How to fill out statement of revocation i

01

Step 1: Start by writing your personal information at the top of the statement, including your full name, address, and contact information.

02

Step 2: Indicate the date on which you are writing the statement.

03

Step 3: Clearly state that you are revoking a previous statement or document. Provide details of the document or statement being revoked, such as its title, date, and any reference numbers.

04

Step 4: Clearly express your intention to revoke the document or statement and your reasons for doing so.

05

Step 5: Sign and date the statement at the bottom.

06

Step 6: Make copies of the completed statement for your records.

07

Step 7: Consider seeking legal advice or assistance if you have any doubts or specific requirements regarding the revocation process.

Who needs statement of revocation i?

01

Anyone who wishes to formally revoke a previous statement or document can make use of a statement of revocation.

02

This may include individuals who have changed their minds about a previous decision, want to cancel a contract or agreement, or need to clarify that a previously provided statement should no longer be considered valid.

03

The specific circumstances in which a statement of revocation is required may depend on local legal requirements and the nature of the original statement or document.

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