Patient rights

Revoke a HIPAA authorization

You have the right to revoke any HIPAA authorization you've signed with Servants Mission, at any time. Submit your revocation here. We honor every revocation within 24 hours of verifying your identity.

Awaiting counsel review

Notice for the patient

Revocation is a federally-protected right under 45 CFR §164.508(b)(5). When we receive your revocation, we stop using or disclosing your information under the revoked authorization. Important: revocation does NOT affect actions Servants Mission already took in good-faith reliance on the authorization before we received your revocation. Once your identity is verified, all in-flight disclosure attempts against the revoked authorization fail closed within 24 hours. The formal revocation-rights notice will replace this placeholder once counsel has signed off.

Source: _docs/HIPAA_OPERATIONS_BLUEPRINT.md → Gate 4

Do not include PHI in this form

Don't include health details — describe in plain terms. We don't need diagnoses, medications, or treatment details to honor your revocation. Compliance will verify your identity using the email or phone on the original authorization.

Patient identification (required)

We need enough information to match your revocation against the authorization on file and to contact you for identity verification.

Patient full name

The name on the original authorization.

Patient email

Provide email or phone (at least one).

Patient phone

Required if no email is provided.

About the revocation (optional)

Every field in this section is optional. Leave any of them blank if you don't know or don't want to share.

Authorization reference

If you know the authorization number, ID, or date you signed, include it here.

Recipients this revocation applies to

List the people or organizations you no longer want to receive your information. Leave blank to revoke ALL active authorizations.

Reason for revocation

You don't have to give a reason. If you'd like to share, it helps us improve. Don't include health details — describe in plain terms.

When should the revocation take effect?

Most revocations take effect immediately upon identity verification. You may instead specify a future date.

Immediately (recommended)

On a specific date

Who is submitting this revocation?

Personal representatives may revoke on behalf of the patient per 45 CFR §164.502(g). Compliance will request proof of representation during identity verification.

What happens next?

Compliance reviews your revocation within one business day.
We verify your identity against the authorization on file. We'll contact you using the email or phone number on the original authorization.
Once verified, the revocation takes effect immediately. The original authorization is marked revoked in our system. Any in-flight disclosure attempts against the revoked authorization fail closed (won't go through).
You receive written confirmation within seven business days. Save the case ID below in case you need to follow up.

Revoking on behalf of someone else?

Personal representatives — parents of a minor, legal guardians, and people with a Power of Attorney (POA) for healthcare — may revoke an authorization on behalf of the patient under 45 CFR §164.502(g). Choose the relationship that fits in the form below; Compliance will request proof of representation during identity verification.

In an emergency

If you or someone you support is in immediate danger, call 911. A revocation is not the same as an Abuse, Neglect, or Exploitation (ANE) emergency — for an active safety threat, the safety reporting channels listed on the Contact page are the right path.

Notice for the patient

Source: _docs/HIPAA_OPERATIONS_BLUEPRINT.md → Gate 4

What happens next?

Compliance reviews your revocation within one business day.

We verify your identity against the authorization on file. We'll contact you using the email or phone number on the original authorization.

Once verified, the revocation takes effect immediately. The original authorization is marked revoked in our system. Any in-flight disclosure attempts against the revoked authorization fail closed (won't go through).

You receive written confirmation within seven business days. Save the case ID below in case you need to follow up.

Revoking on behalf of someone else?