Revocation and Conditions: I understand that I have the right to revoke this authorization at any time by notifying the provider in writing with written name and date of birth of said patient. I understand that revocation of this release will not apply to information that has already been released and does not apply to my insurance company when law provides my insurer with the right contest a claim under my policy. I understand that the information disclosed is protected by law and may not be re-disclosed without my written permission or authorized by law. Above provider reserves the right to release information permitted by authorizer in any manner the we deem to be appropriate and consistent with applicable law, including but not limited to, verbal, paper, or electronic format, I understand there is a potential that the private information may no longer be protected by HIPPA once release from provider to receiver and Julia D. Burrow, MD and Associates are not legally responsible for any of the information once it leaves the facility.