Revoking Access

Please complete the form below to submit for revoking of access to myCHP. Expect a 2-buisness day turnaround.

Patient Name:

Patient Date of Birth:

Requestor Name:

Requestor Phone Number:

Requestor Email Address:  

Requestor's Relationship to Patient:


Other:


User's Access to Revoke:

User's Relationship to Patient:


Other:


Reason for Request:

Electronic Signature:


----------------- For Office Use Only -----------------

Standard Request: Yes / No

Details:


Date Revoked:

Revoked By:


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