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Revocation of Authorization

You must complete this form if you want to revoke an authorization to release information about you that is currently on file with Prime Therapeutics. If you are completing this Revocation of Authorization for a different member than yourself, please download the PDF and submit using the instructions provided on the form. This can be found on the forms page.

Member Information (person revoking release of information)

My revocation request applies to information including: personal and/or health information created or held by Prime Therapeutics. This information may include my address, date of birth, membership status, and medical claim prescription history.

You may NO LONGER release this information to:

Authorized representative