Get the free ECU Patient Revocation of Authorization for Use or Disclosure ...

EAST CAROLINA UNIVERSITY HEALTH CARE COMPONENTS Page 1 of 2 Revocation of Authorization for Use or Disclosure of Protected Health Information Name: Date of Birth: Address: Phone Number: I revoke my

How to fill out ecu patient revocation of

How to fill out ecu patient revocation of

1. Obtain an ECU Patient Revocation of Authorization form.
2. Read the instructions carefully to understand the purpose and use of the form.
3. Fill out the form with your personal information, including your full name, date of birth, and contact details.
4. Provide the name of the healthcare provider or organization from which you revoke authorization.
5. Specify the type of medical information or records that you want to revoke authorization for.
6. Sign and date the form to indicate your consent and understanding of the revocation process.
7. Make a copy of the completed form for your records.
8. Submit the original form to the appropriate healthcare provider or organization.
9. Keep track of any confirmation or acknowledgment received from the recipient of the revocation form.
10. Periodically check with the healthcare provider or organization to ensure that your revocation request has been processed successfully.

Who needs ecu patient revocation of?

1. Individuals who have previously given authorization for their medical information to be shared with a specific healthcare provider or organization.

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