I understand that you will provide this information within 15 business days from the receipt of request, and you may charge a fee for preparing and furnishing this information.
I understand the following: See CFR. § 164. 508(c)(2)(i-iii)
A. I have a right to revoke this authorization in writing at any time, except to the extent information has
been released in reliance upon this authorization.
B. The information released in response to this authorization may be re-disclosed to other parties.
C. My treatment or payment for my treatment cannot be conditioned on the signing of this authorization.
Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein.
This authorization shall be in force and effect until 1 year from date of execution at which time this authorization