At which time this authorization to use or disclose protected health information expires.
* I understand that, as set forth in the practice's Notice of Privacy Practices, I have the right to revoke this authorization, in writing, at any time by sending written notification to the Advanced Counseling Services Privacy Officer.
* I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.
* I understand that the practice will not condition my treatment on whether I provide authorization for the requested use or disclosure.
* I understand I have the right to:
Inspect or copy my protected health information to be used or disclosed as permitted under federal law (or state law to the extent the state law provides greater access to rights).
Refuse to sign this authorization