I may inspect or copy the protected health information to be used or disclosed
I may revoke this authorization in writing by contacting your office at the address above, attention Privacy Officer
Information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer be protected by HIPAA
I may refuse to sign this authorization and that you will not condition treatment or payment on me providing authorization (except to the extent that the authorization is for research-related
If this line is checked, I understand that you will receive compensation from a third party for the use or disclosure of my information.