I request a revocation of a previous authorization to release protected health information (PHI) by Fraser to a third party. This revocation, the specifics of which are indicated below, will be effective from the date in which Fraser acknowledges or accepts this completed and signed form until further notice. I understand this revocation request does not apply to any valid releases of protected health information prior to the date Fraser receives this form.
I also understand if I revoke or restrict permission for Fraser to release PHI to my insurance company that I may be responsible for any further costs associated with any of Fraser's services and programs for dates of service on/after the date Fraser receives this completed and signed form. I understand revoking the release of information to other providers may affect the provider's ability to provide services to me.