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I understand that unless otherwise limited by state or federal regulations, and except to the extent that action has been taken which was based on my consent, I may withdraw this consent at any time by giving written notice to MindDevelopers Counseling & Supervision PC. If no prior notice of revocation is received, this consent will expire automatically two (2) years after the date indicated thereon. I further understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPAA Privacy rule.

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