Free Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization, HCF 13167 - Wisconsin


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DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 13167 (Rev. 01/05)

STATE OF WISCONSIN P.L. 104-191

WISCONSIN SENIORCARE

HIPAA PRIVACY REVOCATION OF AUTHORIZATION
The Privacy Rule standards of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) P.L. 104-191 require DHFS, as a covered entity, to implement processes that give patients certain rights regarding individually identifiable health information. The information requested on this form is needed to comply with those Privacy Rule requirements. Provision of the information that is requested on this form is voluntary. Although the use of this version of the form is voluntary, all of the information outlined on this form is mandatory. Personally identifiable information requested on this form is mandatory in order to process your request and will only be used for this purpose. INSTRUCTIONS: Mail this completed form to the following address: SeniorCare Customer Services PO Box 6710 Madison WI 53716-0710 You are entitled to a copy of this revocation of authorization after you sign it. SECTION I RECIPIENT INFORMATION Name Last, First, Middle Initial

SeniorCare Identification Number

Address Street, City, State, ZIP Code

Telephone Number ( )

SECTION II STATEMENT OF REVOCATION I revoke my previous authorization, or part of my previous authorization, for SeniorCare to use and disclosure of my health information records as described below. I understand that this revocation of my authorization will not affect any action SeniorCare or others took in reliance of my authorization before receiving this written notice of my revocation. Initials: Copy of authorization attached: Date of authorization (if known): SECTION III DESCRIPTION OF AUTHORIZATION REVOKED Do you wish to revoke all of the previous authorization or only part of the previous authorization? Select one of the boxes below and complete all information on this form. Please revoke the entire previous authorization. Please revoke only part of the authorization. Health Information: Describe the health information, including the dates of the records that were previously authorized for the use of or for disclosure by SeniorCare. If only a partial revocation, please provide information as to which part of the authorization you wish to revoke. Yes No

Continued

Wisconsin SeniorCare HIPAA Privacy Revocation of Authorization HCF 13167 (Rev. 01/05)

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SECTION III DESCRIPTION OF AUTHORIZATION REVOKED (Continued) Person or Organization Authorized to Use or Disclose: Name or specifically identify the persons or organizations, including SeniorCare, previously authorized to make use of or disclose the health information described previously: Name Telephone Number ( Address )

Name

Telephone Number ( )

Address

Person or Organization to Receive and Use: Name or specifically describe the persons or organizations to whom you had authorized SeniorCare to disclose or let use the health information described previously: Name Telephone Number ( Address )

Name

Telephone Number ( )

Address

SECTION IV SIGNATURES Please sign the form and complete the appropriate information. SIGNATURE Recipient Date Signed

If this authorization is signed by a personal representative on behalf of the recipient, provide a copy of the documentation to support the representation and complete the following: Name Personal Representative Relationship to Recipient

SIGNATURE Personal Representative

Date Signed