I acknowledge that I have the right to inspect and receive a copy of the health information I have authorized to be used or disclosed by this form. I understand that Esco Drug Company may charge a fee
for the costs of copying, mailing or other supplies to respond to this request. I also acknowledge that I may modify or terminate this authorization in writing at any time. I understand that any modification or termination will not apply to uses or disclosures that have already occurred based on prior authorization or any use or disclosure that is required or permitted by law. !further acknowledge that information used or disclosed pursuant to this authorization may be subject to re-disclosure and no longer protected by federal privacy law.