Patient Forms
    
   
Patient Demographics
   
  New Patient Medical Information
   
  Authorization for Disclosure
  (Release of Medical Records)
  Revocation of Authorization

button
  (Revoke of Medical Records)    

Revocation of Authorization to Release Protected Health Information (PHI)
 

SOUTHEASTERN CARDIOVASCULAR CONSULTANTS
7777 HENNESSY BOULEVARD
SUITE 8000
BATON ROUGE, LOUISIANA  70808
Phone: (225) 767-1151             Fax: (225) 769-7348
 

I, hereby revoke the authorization for Southeastern Cardiovascular

 

(Name of Individual)
Consultants (SCVC) to use and disclose my protected health information to carry out treatment, payment or health

care operations that I signed on .  However, SCVC may use and disclose my

 

(Date of Original Authorization)

protected health information after I revoke my authorization, if SCVC treated me and I stated on the authorization form that SCVC could use and disclose my protected health information for treatment, payment or health care operations prior to treatment. SCVC may no longer use or disclose my protected health information without my authorization after SCVC has treated me, obtained payment, and is no longer required to use or disclose my protected health information.
 

SPECIAL PROVISIONS

In this section, the individual should outline any special provisions regarding the revocation of the authorization.
 
 
Enter the code as it is shown:
 
This field helps prevent automated access.
 
 
Date: / /
   
 
Return to top