I understand this consent will automatically expire in ninety (90) days from the date of my signature, or when the request has been processed, whichever comes sooner. I also understand it is subject to revocation in writing at any time before the expiration date except to the extent that action has already been taken. I understand any information previously disclosed would not be subject to my revocation request. Additionally, the information described above may be re-disclosed by Interlachen Pediatric and therefore may no longer be protected by Federal privacy regulations. I may inspect or request copies of any information disclosed by this authorization if Interlachen Pediatrics initiated this request for disclosure. I may refuse to sign this authorization and my refusal to sign will not affect my ability to obtain treatment, payment for healthcare services or eligibility for benefits.
