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Return To: Counter Health Plan ATTN: Compliance 300 S Riverside Plaza, 4th Floor Chicago, Illinois 60606 Fax: (312) 5489940REVOCATION OF AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION (PHI)I.MEMBER:

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How to fill out countycarecomwp-contentuploadsrevocation of authorization to

01

To fill out the revocation of authorization form on Countycare.com, follow these steps:

02

Visit the Countycare.com website

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Navigate to the 'Forms and Documents' section

04

Find the 'Revocation of Authorization' form

05

Click on the form to download it

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Open the downloaded form in a PDF reader

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Fill out the form with accurate and updated information

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Submit the form through the designated online portal or by mailing it to the provided address

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Individuals who wish to revoke their authorization on Countycare.com may need to fill out the 'Revocation of Authorization' form. This form is typically required for any person who wants to withdraw their consent or permission regarding certain services, disclosure of information, or participation in programs through Countycare.com. It is important to consult the specific guidelines and regulations related to the revocation process as set by Countycare.com.

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What is countycarecomwp-contentuploadsrevocation of authorization to?

The revocation of authorization form is used to cancel any previously granted permission or consent.

Who is required to file countycarecomwp-contentuploadsrevocation of authorization to?

Anyone who no longer wishes to give authorization or consent for a specific action or decision.

How to fill out countycarecomwp-contentuploadsrevocation of authorization to?

The form typically requires the individual to provide their name, contact information, details of the authorization being revoked, and a signature.

What is the purpose of countycarecomwp-contentuploadsrevocation of authorization to?

The purpose of the form is to officially withdraw any previous permission or consent that was given.

What information must be reported on countycarecomwp-contentuploadsrevocation of authorization to?

The form may require details of the initial authorization, reasons for revocation, and any relevant identification numbers or references.

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