Revoke Agent Authorization

Prescriber on File

Enter the prescriber's details so we can match this notice to the authorization on file.

First name *

Last name *

Email *

NPI Number *

Submitted By

Confirm who is sending this notice. If you're submitting on behalf of the prescriber, share your contact info so we can follow up if needed.

I am the prescriber named above.

Agents to Revoke

Enter the name and email of each agent whose authorization is being revoked. We use the email to locate the agent in our system.

Agent 1

First name *

Last name *

Email *

Used to identify the agent in our system

Not the prescriber?

This revocation must be signed by the prescriber. Send them a secure link and everything you've filled in will be ready for their review and submission.

Prescriber email *

Your name

So the prescriber knows who sent it

Your email

Optional — we'll copy you on the email to the prescriber and again when they sign

Revocation Details

Effective date *

Reason

Optional — e.g. 'No longer employed at the practice.'

Also email the revoked agent(s) a courtesy notice.

By sending this notice, you confirm the agent(s) listed are no longer authorized to transmit prescriptions on behalf of the prescriber.