Your Rights With Respect To This Authorization:
I understand that I have the right to inspect or have a copy of the confidential information I have authorized to be used or disclosed by this authorization form. I understand that if I agree to sign this authorization, which I am not required to do; I must be provided with a signed copy of the form. I understand that I am under no obligation to sign this form and that the person and/or agency listed above who I am authorizing to use and/or disclose my information may not condition treatment, payment enrollment in a health plan or eligibility for health care benefits on my decision to sign this authorization. I understand written notification is necessary to cancel this authorization. To obtain information on how to withdraw my authorization, I may contact Jewish Family Services staff providing/coordinating my services. I am aware that my withdrawal will not be effective as to uses and/or disclosures of my health information that the person and or agency listed above have already made in reference to this authorization.