Revoke HIPAA Authorization

The purpose of this webform is to revoke your prior authorization for Color to disclose health information. For this form to constitute a valid revocation, it must be completed and submitted by the subject individual or their parent/guardian. This revocation of authorization will not affect any action Color or any other entity took in reliance on the authorization to disclose health information prior to the date of Color’s receipt and processing of this revocation.

Name^*

Date of Birth^*

Phone Number^*

Email Address^*

Address^*

By completing and submitting this form, I am revoking my prior authorization for the use and/or disclosure of the protected health information described in HIPAA Authorization.

I understand that this revocation of my authorization will NOT affect any action Color or others took in reliance on my authorization prior to the date Color receives and processes this revocation.

Name^*

Date^*

Personal Representative’s Name

Relationship to individual

I understand that by completing this information and selecting this checkbox, this shall constitute an electronic signature and has the same effect as my handwritten signature.^*