REVOCATION & EXPIRATION OF RELEASE AUTHORIZATION
You may revoke this Authorization at any time: the revocation will not apply to information that has already been released in response to this Authorization.
You must revoke this Authorization in writing.
The procedure for revoking this Authorization is to mail your written revocation to:
East Lake Acupuncture, 1551 Budinger Ave., Saint Cloud, FL 34769 or fax it to (321) 340-3522.
You may refuse to sign this Authorization: East Lake Acupuncture, LLC, will not condition your treatment, any payment, enrollment in a health plan, or eligibility for benefits on receiving your signature on this Authorization.
Unless you specify an expiration date, under "Special requests/comments/conditions, this Authorization shall remain in effect indefinitely.
You will not receive any type of compensation for the use of your image(s).