University of Tennessee Health Science Center
Subject: Revocation of authorization for access, disclosure and release of protected
health information.
Effective: April 14, 2003
Objective
To define the process for patients or patient representatives to revoke an authorization for
access to protected health information.
Policy
Patient authorization is required to release information from the medical or dental record.
Patient authorization is also required to revoke authorization.
Procedure
The patient must complete a request for Revocation of Authorization form or submit a
request in writing that contains the same information provided for in UTHSC’s
Revocation of Authorization Form. Once this form is received, no further disclosures
will be made in response to the authorization. The original authorization and the
revocation of authorization will both be filed in the medical or dental record.