I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this authorization to the person or organization under “WHO CAN RECEIVE AND USE THE HEALTH INFORMATION.” I understand that prior actions taken in resilience on this authorization to access my health information will not be affected.
I have read this form and agree to the uses and disclosures of the information as described. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.
I understand that this information will be provided within 15 days from receipt of request and that a fee for preparing and furnishing this information may be charged according to rulings set forth by the Texas State Board of Medical Examiners.