Health Information Portability and Accountability Act (HIPAA) authorization forms allow your medical providers and insurance companies to share your personal medical information. The time may come, though, when you want to amend your HIPAA authorization. You, under HIPAA laws, may revoke your HIPAA authorization by filling out a simple form, according to the Department of Health and Human Services. You can access this form from most HIPAA-covered providers. However, you can also construct your own should the need arise.
Contact the provider for which you would like to revoke your HIPAA authorization. Sometimes the healthcare provider can provide you with a form to fill out. If the organization does not possess a form for you to fill out, continue to Step 2. If they do, continue to Step 3.
Type the following information on a piece of paper: your name, address, telephone number and the statement (developed from FSAFEDS), “I revoke any authorizations to release medical, healthcare and insurance-related information by [insert organization name] to any third party.” Sign the form.
Mail the form to the healthcare provider. Although this form allows you to prevent any further disclosure of healthcare related information, the Department of Health and Human Services makes it clear that certain information can be shared, such as information determined critical and life-saving in an emergency room.
Call the provider within two week's time to ensure that they received your form. Request a letter of receipt.
If you revoke authorization and the provider continues to share your information, the law requires that the provider correct the consequences of this disclosure within a month or face prosecution, according to the UC Davis Health System.