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Not finding what you need in this section for members and insurance shoppers? Check out our other help sections below.

You can use this form when you want to stop sharing your protected health information with a person or place you previously authorized.

What you’ll need:

  • Your enrollee ID card
  • A printer to print the form
  • An envelope and postage to mail the form, or a fax machine. Each form includes instructions, a mailing address and a fax number.

If you have any questions, please contact us.

Authorization to Revoke a Previous Authorization (PDF)

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