I certify that my health information is being disclosed at my request or at the request of my personal representative. I understand that treatment, payment, enrollment in a health plan, or eligibility for benefits is not dependent on my signing this authorization. By signing below, I acknowledge that I have read and understand this document and that I have voluntarily given CCS/my provider authorization to disclose my records. I understand that I may revoke this authorization at any time by providing a written notice to my provider. However, the revocation will not have an effect on any actions taken prior to the date my revocation is received.