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Please make a selection to tell us whether you would like to unsubscribe from future communications or cancel your authorization to allow access to information protected by HIPAA. Following your selection, please fill out the form provided to complete your request.

Cancel HIPAA authorization

By completing the form below, I understand that I am canceling (revoking) my prior HIPAA Patient Authorization Form. UCB shall provide timely notification of my cancelation (revocation) to my Providers and Insurers. Once my Providers and Insurers receive and process the notice of cancelation (revocation) of this Authorization, my Providers and Insurers may no longer make disclosures of my Protected Health Information to UCB as permitted by this Authorization. However, canceling this Authorization will not affect any action(s) taken by my Providers or Insurers based on this Authorization before receipt of my notice of cancelation. I understand that I have a right to receive a copy of this authorization.

I would like to cancel my HIPAA authorization with regard to the following conditions:

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I would like to unsubscribe from communications about the following conditions:

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