2. I understand that I may revoke this authorization at any time by writing to Bayshore Pharmacy, 2 Bayshore Plz, Atlantic Highlands NJ 07716, except to the extent that Bayshore Pharmacy has taken action in reliance on this
3. I understand that I am signing this Authorization of my own free will and that this authorization will not affect my ability to obtain treatment from the Pharmacy. I hereby state that this disclosure is at my request. A photocopy or facsimile of this signed authorization is as valid as the original and will be accepted. 4. I understand that if the person or entity that receives my PPR is not required to comply with the federal privacy regulations, the information described above may be redisclosed and would no longer be protected by those regulations. 5. This Authorization will expire 6 months from the dated signature on this authorization.