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.

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. 

If this revocation is signed by a personal representative (e.g., parent/guardian) or behalf of the subject individual, please complete the following:

Thank you for your submission. You should receive an email at the address provided confirming your revocation was submitted.  Please note that it may take Color up to 5 days to process this request.