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AUTHORIZATION TO USE AND/OR DISCLOSE HEALTH INFORMATION Revocation Date Revoked: Initials of Privacy Official Patient Name: Medical Record No. Address: I authorize ABC Pediatrics, PC to use or disclose
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What is date revoked?
Date revoked refers to the official termination date of a particular document or agreement, indicating when it is no longer valid.
Who is required to file date revoked?
Typically, entities or individuals who have previously submitted a document that is now being revoked are required to file a notice of date revoked.
How to fill out date revoked?
To fill out a date revoked form, you generally need to include the title of the document being revoked, the effective date of revocation, and any relevant identification numbers or details pertaining to the original document.
What is the purpose of date revoked?
The purpose of date revoked is to formally notify all relevant parties that a specific document or agreement is no longer in force, preventing any legal or operational confusion.
What information must be reported on date revoked?
Information usually includes the document type, identification numbers, the effective date of revocation, and the parties involved.
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