This authorization lasts for one year after the date it is signed. This authorization may be cancelled in writing at ANYTIME. A cancellation will not change the releases’ that happen prior to the time the cancellation notice is received. TO CANCEL A RELEASE, call or send a request to the “Requested Release Form” address above. A photocopy or fax of this authorization will be treated the same as an original. Consulting Radiologists, Ltd. and its affiliates; CRL Imaging, CRL Women’s Imaging, LifeScan Minnesota, and Twin Cities Medical Imaging CANNOT prevent re-disclosure of your information by the person or organization who receives your records under this authorization, and that information may not be covered by the State and Federal privacy protections once it is released. By signing the document below, you release Consulting Radiologists, Ltd. and its affiliates; CRL Imaging, CRL Women’s Imaging from any liability from a re-disclosure by the recipient. Consulting Radiologists, Ltd. and its affiliates; CRL Imaging, CRL Women’s Imaging WILL NOT condition treatment on whether you sign this form. By checking the 'I accept' box BELOW, this form indicates that you have read and understand this form, authorize release of your information as described above. *CRL is not responsible for loss of information submitted online through our secure form.