I UNDERSTAND THAT:
▪ I may revoke this Authorization at any time.
o The revocation will not apply to information that has already been released in response to this Authorization.
o I must revoke this Authorization in writing. The procedure for revoking this Authorization is to present my written revocation to the Front Office staff.
▪ I may refuse to sign this Authorization.
o My treatment, payment, enrollment in a health plan, or eligibility for benefits cannot be conditioned upon my authorization of this disclosure.
o A fee may be charged for providing the protected health information. Please contact our office to obtain fee and
I understand that the information released may include sensitive information related to behavior and/or mental health, drugs and alcohol, HIV/AIDS and other communicable diseases, and genetic testing.
I have been informed and understand that information disclosed pursuant to this Authorization may be subject to redisclosure by a recipient of such information. It is possible that once disclosed, the privacy of the information may no
longer be protected under federal medical privacy law.
Unless otherwise revoked, this authorization will expire on the following date, event, or condition: