______________________________________________________________________________________________
_____________________________________________________________________
.
ROUTE TO:
CAMERON UNIVERSITY
Health Plan
Revocation of Request for Restrictions on Use and Disclosure of
Protected Health Information Health Plan
I, do hereby revoke my Request for Restriction on Use
and Disclosure of PHI, effective on the date of my signature. I understand that my
Revocation may take up to two weeks to process. I understand that this Revocation
applies to any and all Requests for Restrictions I may have been granted by the
Cameron University.
Printed Name (and Title, if Le gal
Representative*) Signature Date
For Department Use Only:
Revocation Processed by on 20
*May be requested to show proof of representative status
File in Member Chart HIPAA Document
01/2015 © 2015 Retain for a minimum of 6 years
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