Revocation of Authorization to Disclose Health Information Form

Xavier University of Louisiana

Office of Student Health Services Office: (504) 520-7396

1 Drexel Drive – Box 36 Fax: (504) 520-7962

New Orleans, LA 70125

This form is used to revoke previously authorized disclosure. The Health Insurance Portability and

Accountability Act of 1996 (HIPAA) provides an individual the right to revoke a previous

authorization to disclose protected health information at any time.

Patient Information:

Name: ___________________________________ D.O. B. ______/______/______

ID# or SSN: _______________________________ Phone #: __________________

Statement of Revocation:

I hereby revoke any previous authorizations to disclose my protected health information (PHI)

I understand that this revocation of my authorization will only apply to further disclosures

regarding my personal health information and cannot cancel actions or disclosures made before

receiving this written notice of my revocation.

Description of Authorization Revoked:

Date of original authorization (if known): _____/_____/_____

Copy of authorization attached: Yes ___ No ___

Person or Entity authorized to receive the information:

______________________________________________________________________________

Specific description of information to be revoked. (Information you authorized to be released)

______________________________________________________________________________________

This authorization must be signed and dated below by the patient or legal guardian to be

valid. Parents or legal guardians must also include their name and relationship to the

patient.

Patient Signature: _____________________________________________ Date: ____/____/____

Parent/Legal Guardian Name: ______________________________________________________

(Please Print)

Legal Guardian Relationship to Patient: ______________________________________________

Parent/Legal Guardian Signature: ________________________________ Date: ____/____/____

Please retain a copy of the revocation form for your records and a copy will be kept on file

in your medical record for the time period according to Louisiana record retention law.