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Seattle Children’s Hospital
Revocation of Authorization
*57097*
57097
®
REVOCATION OF AUTHORIZATION
You have the right to revoke your Authorization to release Patient Health Information. To do so, this form must be
completed and returned to Seattle Children’s Health Information Management department.
Patient Name:
Last First
Middle
Date of Birth:
Month Day Year
I, as the patient or legal representative of the above patient, hereby revoke (cancel) my previous authorization and
withdraw my permission for Seattle Children’s to share records and/or communicate with:
Person/Organization Name:
Person/Organization Address:
Street Address
Approximate Date Signed:
City State Zip Code
I understand that:
This revocation will not be in effect until Seattle Children’s Health Information Department has confirmed
receipt and is allowed 5 business days to process.
This revocation applies to the future sharing of information. Information that has already been shared with my
written permission or for continuity of care purposes cannot be recalled.
Health information will be disclosed when required by law; for example, to report infectious diseases.
Signing this cancellation is voluntary; I do not need to sign this form to assure treatment.
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Patient/Legal Representative Name Relationship to Patient
Date Signed
Patient/Legal Representative Signature
Signature of minor patient (13-17 years of age) is required to revoke an authorization, if the following information was
previously included on prior authorization: conditions relating to reproductive care, sexually transmitted infections
(including HIV/AIDS) (age 14 and older), mental health conditions (age 13 and older), and drug and alcohol abuse
diagnosis or treatment (age 13 or older).
Signature of Minor Patient Date Signed
After completing this form, you may submit it by:
Giving the form to clinic or unit staff. They will forward it to the Health Information Management department.
Mailing or faxing the form to Health Information Management (see address/fax below).
Emailing your request to HealthInformationManagement@seattlechildrens.org.
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PATIENT LABEL HERE
PO BOX 5371 MAIL STOP S-216
SEATTLE, WA 98145-5005
PHONE: 206-987-2173
FAX: 206-985-3252
