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Process for Revoking an Active Medical Record Authorization Request:
All revocations for active authorizations (not yet expired) for inpatient and intensive outpatient (IOP) medical records for La Hacienda Treatment Center, La Hacienda's Solutions, and La Hacienda College Station patients can be sent to our central Medical Records Department located in Hunt, Texas. The revocation will begin as soon as the notice is received in our office.
Download this form from our secure site, complete and sign the Revocation of Authorization to Release Protected Health Information Form and return the completed form to us by U.S. Mail, courier service such as FedEx or UPS, or fax.
PLEASE NOTE: We cannot accept this form by e-mail as e-mail is not secure. If you do so, it is at your own risk.
Medical Records/HIM Contact Information:
La Hacienda Treatment Center
Medical Records Dept.
P.O. Box 1
Hunt, TX 78024
Phone: 800.749.6160 ext. 605
Fax: 830.238.6119
Medical Records/HIM Hours of Operation:
Monday through Friday, 8:30 a.m. to 4 p.m. Central Standard Time. After hours, please leave a confidential voice mail, and we will return your call.
Download the Revocation of Authorization to Release Protected Health Information  (Size: 128KB) |
