This revocation is given freely and with the understanding that:
· Disclosures made in good faith may have already occurred based on my previously issued authorization and that this revocation cannot apply retroactively to such disclosures.
· I understand that the disclosure of health information may be required by law in certain limited instances despite this revocation.
· The revocation becomes effective once it is received by Kenneth Young Center.
· Records already released by the valid authorization cannot be retracted.
· The facility, its employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the information I previously authorized.