This authorization will expire at the end of the calendar year, unless you specify an alternate date. You must submit a new authorization form after the calendar year to continue the authorization. Please list the date of expiration if other than the end of the calender year _____________________
You have the right to terminate this authorization at any time by submitting a written request. Termination of this authorization will be effective upon written notice, except where a discussion has already been made based on prior authorization.
We have no control over the person(s) you have listed to receive your protected health information. Therefore, your protected health information disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule and will no longer be the responsibility of the practice.