Re-disclosure: I understand that when the information is disclosed pursuant to this Authorization to someone who is not required to comply with the federal or state privacy protection requirements, it may be subject to re-disclosure by the recipient and may no longer be protected.
Revocation: I understand that I may revoke this Authorization at any time by writing to the address above. A request to revoke my authorization will not apply to the extent that SHCC has taken action in reliance upon this authorization.
Conditioning of Eligibility: SHCC will not condition treatment, payment, and enrollment or benefit eligibility on my signing this document.
If you are under age 18, your legal parent/guardian must sign this form.