Form 0920-0891 Designated Representative Revocation Form

World Trade Center Health Program

Designated Representative Revocation Form

INSTRUCTIONS: This form must be filled out in its entirety by a WTC Health Program applicant/member or their personal representative.¹ If you are interested in removing your designated representative, you only need to fill out this form. If you are interested in changing your designated representative, you need to also fill out the Designated Representative Appointment and HIPAA Authorization for Designated Representatives forms. Please return all documents to the WTC Health Program via mail ATTN: WTC Health Program Privacy Officer at P.O. Box 7000 Rensselaer, NY 12144 or via fax at 404-448-4485.

I, __________________________, want to withdraw my appointment of ______________________________

name of applicant/member name of DESIGNATED REPRESENTATIVE

as my designated representative for purposes of the WTC Health Program, meaning that they will no longer be able to make requests or give direction to the WTC Health Program on my behalf regarding administrative matters.

I also want to revoke the HIPAA Authorization I submitted allowing the WTC Health Program to disclose my

protected health information to the above individual, including protected health information contained in medical, treatment, and diagnostic records.

I understand that any use or disclosure of information by the WTC Health Program made prior to the Program’s receipt of my written request to revoke this authorization will be governed by the previous authorization to the extent that the Program has taken any action in reliance on it.

Printed Name of Applicant/Member Date of Birth

Address WTC Health Program ID# (911#), if known

Phone

Applicant/Member Signature Date

1 If the signatory is not the applicant/member, please include documentation demonstrating the signatory’s legal authority to act on behalf of the applicant/member for HIPAA-authorized purposes.