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Servants MissionServants MissionWithdraw a permission you previously gave to share your information.
When you have signed an authorization allowing Servants Mission Inc. to use or share your health information, you may revoke (cancel) it at any time.
How to revoke. Submit your revocation in writing using the form on this page, or send a signed, dated statement identifying the authorization you wish to cancel.
When it takes effect. Your revocation takes effect when we receive it, except to the extent we have already acted in reliance on it. A revocation cannot undo a use or disclosure we already made in good faith while the authorization was in effect.
One limited exception. Where an authorization was obtained as a condition of obtaining insurance coverage, other law may give the insurer a right to contest a claim or the policy itself even after you revoke.
Revoking an authorization does not affect actions taken while it was valid, and does not change our right to use or share your information where the law otherwise permits or requires it (for example, for treatment, payment, or operations as described in our Notice of Privacy Practices).
Questions: our Privacy Officer, privacy@servantsmission.net.
45 CFR §164.508(b)(5); representatives under 45 CFR §164.502(g)
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.