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The Revocation of Authorization to Disclose Health Information is a crucial document in the German healthcare system, designed to protect patient privacy rights under both German national law and EU GDPR. It becomes necessary when a patient wishes to withdraw previously granted consent for sharing their health information. This document type is particularly relevant in situations where patients want to restrict access to their medical records, change healthcare providers, or modify their data sharing preferences. It must comply with the German Federal Data Protection Act (BDSG), relevant provisions of the German Civil Code (BGB), and healthcare-specific regulations. The document ensures that healthcare providers immediately cease sharing the specified health information while acknowledging that any disclosures made under the previous authorization remain valid. It's an essential tool for maintaining patient privacy rights and data protection compliance in the German healthcare context.

1. Patient Information: Full name, date of birth, address, and insurance number (if applicable) of the patient revoking the authorization

2. Healthcare Provider Information: Details of the healthcare provider(s) or institution(s) to whom the original authorization was given

3. Original Authorization Reference: Date and specific details of the original authorization being revoked, including any reference numbers

4. Revocation Statement: Clear and explicit statement revoking the previous authorization to disclose health information

5. Scope of Revocation: Specific description of what health information is covered by the revocation

6. Effective Date: Statement of when the revocation takes effect

7. Acknowledgment: Statement acknowledging that the revocation cannot affect any disclosures made prior to processing the revocation

8. Signature Block: Space for patient's signature, date, and any witness requirements