Right to cancel. I understand that I have a right to revoke this authorization at any time with written notice to info@microtransponder.com and that, unless revoked sooner, expires fifteen (15) years from the date the authorization is signed. I understand any actions already taken based on this authorization will NOT be affected.
Risk of redisclosure. I understand that any disclosure of my health information carries with it the potential for re-disclosure and that after disclosure my health information may not be protected by Federal or state privacy rules.
My choice. I understand that I can choose not to sign this authorization and consent and that my provider(s) may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this form. My signature below acknowledges that I have read and understand this form, and I consent to the sharing and use of my information as described above.