I understand that the above named agency/facility/person authorized to receive or exchange this information has the right to inspect and copy the information to be disclosed. I further understand that if the entity receiving this information is not a healthcare provider/plan covered by HIPAA privacy regulations, the information described above may be re-disclosed and longer protected by the HIPAA Regulations.
I understand that I may revoke this consent at anytime (revocation must be in writing). I understand that said revocation of this consent shall not be effective to prevent disclosure of records and communications until it is received by the person otherwise authorized to disclose records and communications.
It has been explained to me that if I refuse to the release, reception or exchange of information specified above the following are the consequences. *Specify consequences: INFORMATION WILL NOT BE DISCLOSED/OBTAINED