· I understand this authorization will expire in 1 year after I have signed this form.
· I understand I may revoke this authorization at any time by notifying the providing organization in writing, and the revocation will be effective on the date notified except to the extent action has already been taken.
· I understand information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by Federal privacy regulations
· I understand that while there is usually no charge for medical records if copies are sent for ongoing care or follow up treatment, some facilities charge for transfer of records. The patient is responsible for any charges related to the transfer of records.