Affirmation of Release By signing and completing this form, I give the above-identified clinician permission to release only the information I have selected on this form to the individual or agency I have named and only for the purposes designated. I understand that I may refuse to sign this authorization. I also may revoke this authorization at any time in writing, and it will take effect on the day it is received. Any revocation or refusal to sign this authorization will not affect my ability to obtain treatment or payment or my eligibility for benefits. As a patient, I have the right to access my treatment records as allowed by HIPAA. Copies of the records may be obtained with reasonable notice and payment of copying costs. I understand that if the person or entity that receives the above-specified information is not a health care provider or healthcare entity covered by federal privacy regulations or a business associate of these entities, the information released may be re-disclosed and no longer protected by the regulations and Privacy Rule.