Revoking Your Consent

What To Do When Coerced or Required 
to Sign a Consent or Authorization Form


A far too common issue, patients are often coerced or forced to sign a consent form they do not agree with - simply to receive treatment. In other words, patients are often being placed in the scenario of choosing between protecting their private information or receiving medical care. These should not be mutually exclusive activities; nevertheless, the "bundled" or "one-signature-for-many-consents" forms rarely allow a patient to actually maintain control or privacy over their health information.

As a result, you, as a patient, may need to get creative to protect your information. (Check out the Consent Form page to learn first steps for protecting your information)

If you are unable to actually choose which things you consent to, and which things you do NOT consent to, and you are unable to seek medical care elsewhere, you may wish to use one of these two forms - a Minnesota Version and a National Version. Note: the federal HIPAA rule allows an individual to revoke authorization at any time, and it must be adhered to immediately upon receipt. (HHS Explanation of Revoking Authorization)

National Revocation Form       |       Minnesota Revocation Form:


How to Fill Out the Forms:

The National and Minnesota Revocation Forms are nearly identical. Simply write the name of the health care facility at the top, initial to indicate the items you desire, fill out the patient information section, and sign the form. 
1. If you want to use your insurance company to pay for your medical care, be sure to initial the section and list the insurer as indicated in Sample 1.
2. If you want to pay cash, check, or credit and do not wish your insurer to access your medical record, leave the insurance section blank and do not inital as indicated in Sample 2.
3. If you are in Minnesota and wish to opt-out of the state health information exchange (HIE), initial as indicated in Sample 2.
4. If you are a representative for the patient, complete the bottom section. (ex. Mother or Father signing for a minor child)

National Revocation Form       |       Minnesota Revocation Form:
  SAMPLE 1                                               SAMPLE 2


Two Examples of How the Forms Can Be Used:

A woman with severe stomach pain visits a clinic or hospital, and receives a consent form that contains a number of health information sharing requirements the patient is not comfortable with. After speaking with the receptionist and the manager about only wishing to sign a consent form to be treated and to allow sharing of information with the insurance company to pay for the visit, the woman is told she will not be seen or treated unless she signs the bundled consent form. Because she is in severe pain, the woman acquiesces and signs the form and receives her much needed medical care. However, as she leaves, she hands the receptionist a copy of the Revocation Form which she filled out while waiting to see the doctor. This allowed her to be seen and receive medical treatment, but also then stop as much health information sharing as possible as quickly as possible.

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