Free 51736.pdf - Indiana

Indiana Health Coverage Programs

R E V O C A T I O N

O F

A U T H O R I Z A T I O N

Section A: Statement of Revocation I revoke my previous authorization, or part of my previous authorization, for the Indiana Health Coverage Program's (IHCP's) use and disclosure of my health information records as described below. I understand that this revocation of my authorization will not affect any action the IHCP or others took in reliance on my authorization before receiving this written notice of my revocation. Initials: Name: Address: City, State, ZIP Code: IHCP RID Number: Copy of authorization attached: Yes No Phone Number: Social Security Number: Date of authorization (if known):

Section B: 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 and the dates of the records that were previously authorized for the use or disclosure by the IHCP:

Person or Organization Authorized to Use or Disclose: Name or specifically identify the persons or organizations, including the IHCP, previously authorized to make use of or disclose the health information described above: Name: Address: Phone Number: Person or Organization to Receive and Use: Name or specifically describe the persons or organizations who had authorized the IHCP to disclose or let use the health information described above: Name: Address: Name: Address: Phone Number: (Continued) Phone Number:

State Form 51736 (5-04)/OMPP 0051

Indiana Health Coverage Programs

Revocation of Authorization Form ­ Page 2

Section C: To the member ­ Please sign the form. Signature: Date:

Section D: To the member's personal representative ­ Please sign the form and complete the appropriate information If this request is from a personal representative on behalf of the IHCP member, please provide a copy of the documentation to support the representation and complete the following: Personal Representative's Name: Relationship to IHCP Member: This form must be notarized if submitted by the member's personal representative. Subscribed and sworn (affirmed) before me this Signature: Notary Public in and for the state of In the county of (Affix seal) My commission expires: day of , Date: