RIGHT TO REVOKE: I understand that I can withdraw my permission at any time by giving written consent.
SIGNATURE AUTHORIZATION: I have read this form and agree to the uses and disclosures of the information as described. I understand that refusing to sign form does not stop disclosure of health information tha thas occured prior to revocation or that is otherwise permitted by law without my specific authorization, including disclosures to other covered entities as provided by Texas Health & Safe Code 181.154(c) and/or 45C.F.R. 164.506(a)(1). I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipeint and may no longer be protected by federal or state privacy laws.