My signature below represents that I understand this form is valid for one year from date of signature and may be revoked by me (or my legal representative) at any time in writing to CCS. I also understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment for services or eligibility for benefits. Additionally, I understand that a separate Authorization is needed if I want to give someone full access to my health record.