This authorization will expire one year from the date of the signature below. I understand that I can revoke this authorization at any time by writing to the health care provider, but that revoking this authorization will not affect disclosures made or actions taken before the revocation is received.
I also understand that:
I am not required to sign this authorization and that my health care or payment for care will not be affected by my
Federal privacy regulations will no longer apply to the information disclosed, and that may re-disclose the
I am entitled to receive a copy of this authorization.
A copy of this authorization may be utilized with the same effectiveness as an original.