You, the parent, may refuse authorization to disclose all or some healthcare information but that refusal may result in improper diagnosis or treatment, denial of coverage or a claim for health benefits or other insurance or other adverse consequences.
You, the parent, may revoke this authorization at any time by executing a written revocation, subject to the right of any person who acted in reliance on the authorization prior to receiving notice of revocation. If you do revoke this authorization, that action could result in the denial of health benefits or other insurance coverage or benefits.
You, the parent, must deliver the revocation of your authorization to us by hand, certified mail or by express delivery service.
You are entitled to a copy of this authorization.