By signing this authorization form, I understand that:
Request for copies of medical records are fees in accordance with federal/state regulations.
I have the right to revoke this authorization at any time. Revocation must be made in writing and presented to the Office Manager at the following address: 3277 S Lincoln Street, Englewood, CO 80113.
Unless otherwise revoked, this authorization with expire on the following date/event/condition: If I fail to specify an expiration date/event/condition, this authorization will expire one (1) year from the date signed.
Treatment, payment, enrollment or eligibility for benefits may not be conditioned on whether I sign this authorization.
Any disclosure of information carries with it the potential for unauthorized redisclosure, and the information my not be protected by federal confidentiality rules.