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I may revoke this consent at any time by written notification to Five 14 Revolution. I understand that the revocation has no effect on actions taken prior to the date of revocation. I approve the exchange of information and understand that confidentiality cannot be assured when information is faxed. My initials below signify acceptance of the risk that confidentiality may be breached when information is faxed. I understand that the information provided can be given either written or verbal. I understand that only the information specified below may be disclosed and that the information is protected by the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA). Federal regulations prohibit you from making any further disclosure of this information without specific written consent of the person to whom it pertains, or his/her parent or legal guardian unless otherwise permitted by such regulations. Pursuant to Public Law 93-579, the Privacy Act of 1974, I hereby request and authorize the above named agency or organization to release information on my behalf to Five14 Revolution. I understand that the information released may be sensitive or confidential in nature. This authorization is valid only if received within 60 days of being signed.