08/08/19
PHI09/R10
ENR-1490-PHI09
GE-FRM-0119-009
0G
REVOCATION OF AUTHORIZATION
TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION (“PHI”)
Use this form to revoke permission for GEHA to discuss your PHI with the authorized person(s)
listed below.
About you, the GEHA member whose PHI may no longer be used or disclosed
Plan ID Number:
Member Name: Date of Birth: _______________________
Address:
Telephone Number:
Please place a check mark in front of each plan you want this Revocation of Authorization to be applied:
___ GEHA Health Plan ___GEHA Connection Dental Federal Plan
___ Connection Dental Plus Plan ___CONNECTION Vision Plan
Revocation Information
I previously authorized Government Employees Health Association, Inc. (“GEHA”) and its business associates to
release my PHI to the following persons, and now wish to revoke these prior authorizations:
Name(s):
Relationship(s) to You:
Signature and Acknowledgement
By signing below, I hereby revoke such prior Authorization(s). I understand that PHI may already have been disclosed
by GEHA pursuant to and in reliance on my prior Authorization. I also understand that this revocation applies only to
the information specifically described in the “AUTHORIZATION TO DISCLOSE PROTECTED HEALTH
INFORMATION” form previously signed and sent to GEHA. I understand that this revocation request may require
up to fifteen (15) working days from the date received by GEHA to process this request.
Date:
Patient or Legal Representative Signature:
Relationship to Patient:
(i.e. parent, legal guardian, power of attorney, etc.)
NOTE: If the signature is not that of the patient or the parent when the child is a minor, appropriate legal documentation
is required to accept the signature.
click to sign
signature
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