REVOCATION OF AUTHORIZATION TO RELEASE INFORMATION

I, _____________________________________________________(“Patient”), hereby revoke the authorization to release information I provided to Bellingham Health (“Practice”) that allowed Practice to use and disclose my PHI as I outlined on the authorization form, which I signed on __________________(Date Signed) for release of my PHI to _________________________________________________________. I understand that this revocation does not apply to any action Practice has taken in reliance on the authorization I signed earlier. This revocation does not revoke any and all previous authorizations to release information that I have provided to Practice.

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Signature of Patient or Personal Representative                                      Date

Special Provisions

In this section, the individual should outline any special provisions regarding the revocation of the consent or authorization.

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_____________________________________________________                                  _______________________
Signature of Patient or Personal Representative                                       Date