I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to:
FIRST AID SERVICES, LLC
4238 SPRING COURT
LA MASA CA 91941
I understand that:
1. In the event that my information has already been shared by the time my
authorization is revoked, it may be too late to cancel permission to share my health
2. I understand that I do not need to give any further permission for the information
detailed in Section II to be shared with the person(s) or organization(s) listed in section IV.
3. I understand that the failure to sign/submit this authorization or the cancellation of
this authorization will not prevent me from receiving any treatment or benefits I am
entitled to receive, provided this information is not required to determine if I am
eligible to receive those treatments or benefits or to pay for the services I receive.