I understand that the copying fee for records provided by Fredericksburg Christian Health Center is as follows: $0.50 per page for the first 50 pages and then $0.25 per page for each additional page copied for personal use. Payment for the records must be paid in full before the patient receives the records. I understand that I have the right to access my medical records in accordance with the law and policies of Fredericksburg Christian Health Center. I understand that Fredericksburg Christian Health Center charges me for copies of my medical records for personal use. And I acknowledge of the fee schedule listed above. I hereby authorize disclosure of the health information for the above named patient. This authorization is valid for 12 months from the date of signature. I understand that I may cancel this request with written notification but that will not effect any information released prior to notification of cancellation. I understand that the information used or disclosed may be subject to re-disclosure by the person/s or facility receiving it and would then no longer be protected by federal regulation. I understand that the medical provider to whom this is furnished may not condition treatment of me on whether or not I sign this authorization.