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 subscriber ID card, also known as 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)