REVOCATION OF AUTHORIZATION TO USE AND DISCLOSE CONFIDENTIAL HEALTH INFORMATION

I hereby revoke any and all prior authorizations that I signed in any place at any time entitled THE INDIGENT CARE COLLABORATION: Authorization to Use and Disclose Confidential Health Information.

I understand that it is my right to revoke this authorization, and that my revocation must be in writing and delivered to the ICC to be valid.  I also understand that if I wish to re-authorize the sharing of information at a future time, I will need to sign a new authorization form. 

I understand that there may be a delay between the time the revocation is received by the ICC and the time that my information is removed from further disclosure, but that this delay will generally not exceed seventy two (72) hours. 

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Name of Individual                            Signature of Individual or Authorized Party                                  Date

________________________________________________________________________

Birth Date                             Address                                        Social Security Number (if available)

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(If different from individual) Relationship of Authorized Party to Individual

_________________________________________          __________________________

Witness                                                                                                                                  Date

For this revocation to be valid, please either mail or hand deliver it to the following address, or give it to any participating ICC provider to mail or hand deliver to:

Indigent Care Collaboration

c/o Application Administrator

1213 N. IH-35

Austin, Texas  78702