I understand that I may revoke this authorization at any time, and that my revocation is not effective unless it is in writing and received by the dental practice's Privacy Official at About Faces and Braces.
If I revoke this authorization, my revocation will not affect any actions taken by the dental practice before receiving my written revocation.
I understand that I may refuse to sign this authorization, and that my refusal to sign in no way affects my treatment, payment, enrollment in a health plan, or eligibility for benefits.
This authorization expires on the following date, or when the following event occurs when treatment is completed/terminated.