I understand that:
• My right to health care is not conditioned on this authorization.
• I may cancel this authorization at any time by submitting a written request to the address at the top of this form, except where a disclosure has already been made in reliance on my prior authorization.
• If the person or facility above receiving this information is not a health care or medical insurance provider covered by privacy regulations, the information stated above could be redisclosed.
• There may be a charge for requested records.