I understand that my eligibility for services cannot be conditioned upon my signing this Authorization; however, services to be paid for by any third party are conditioned upon my signing this Authorization for disclosure to the third party when Authorization is required by law or for payment purposes. I am not guaranteed services on the basis of this Authorization. My health information may be protected under federal and state laws and may not be disclosed without my signed Authorization, unless otherwise provided for by state or federal law. Even if I refuse to sign this Authorization, my health information may be used or disclosed without this Authorization when allowed or required by law. Information disclosed under this Authorization may be subject to re-disclosure by the recipient and no longer protected under
I also understand that I may revoke this Authorization in writing to this provider at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires in accordance with the conditions specified in this document.
This Authorization cannot be revoked if the use or disclosure is required for payment to this provider for services provided in reliance on this Authorization.