Patient Revocation Request Form Template

As a covered entity under HIPAA, you can use this form template to receive patient requests for revocation or change of restrictions on health information. This patient revocation request form uses multiple pages, include field validations, and has a customizable design. You can easily customize this patient revocation request form online using our form builder. 123FormBuilder includes various features and a HIPAA-compliance suite that enables you to use this form legally in the US healthcare system.