Duration and Right to Revoke Authorization: This authorization can be revoked at any time by submitting a notice in writing. Such revocation would be effective upon receipt. Unless revoked, this authorization is valid for both the patient and the patient's partner/ spouse. I understand that a revocation is not effective when Fora Fertility has already relied on the use or disclosure of the health information or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. Redisclosure: I understand the information disclosed by this authorization may be subject to re-disclosure by the recipient and will no longer be protected by federal HIPPA regulations. I understand that Fora Fertility will not condition treatment or payment on whether I sign this authorization. However, failure to sign an authorization may result in inability to obtain certain health care benefits, My signature below indicates that I hereby agree and authorize to release of patient health information to the above named person or organization.