I understand that the health information disclosed as a result of this authorization may no longer be protected by the federal privacy standards and my health information might be re-disclosed without obtaining my authorization.
I understand I have the right to:
- Receive a copy of this authorization
- Refuse to sign this authorization and that treatment, payment, enrollment in a health plan or eligibility for health care benefits may not be contingent on my signing this authorization
- Revoke this authorization, except to the extent that the person(s) and/or organization(s) listed above have already made in reference to this authorization
This authorization will remain in effect for 12 months from the date signed below.