I UNDERSTAND I MAY REVOKE THIS AUTHORIZATION AT ANY TIME TO THE ADDRESS LISTED AT THE TOP OF THIS FORM. I UNDERSTAND THAT THE REVOCATION WILL NOT APPLY TO INFORMATION THAT HAS ALREADY BEEN RELEASED IN RESPONSE TO THIS AUTHORIZATION. I UNDERSTAND THAT TREATMENT MAY NOT BE CONDITIONED ON MY AGREEMENT TO SIGN THIS AUTHORIZATION.THIS AUTHORIZATION WILL AUTOMATICALLY EXPIRE ONE YEAR FROM THE DATE OF MY SIGNATURE. I UNDERSTAND THAT ONCE INFORMATION IS RELEASED PURSUANT TO THIS AUTHORIZATION WE CANNOT PREVENT THE REDISCLOSURE TO ANOTHER THIRD PARTY. A COPY OF THIS AUTHORIZATION WILL BE CONSIDERED AS VALID AS THE ORIGINAL.