I understand the following:
*This authorization will expire 1 YEAR from the date this form is signed.
*I may revoke this authorization at any time by notifying the providing organization in writing.
*My notification will be effect on the day it is received, unless action has already been taken on the original request.
*The information used before this authorization may subject to redisclosure by the recipient and no longer protected by federal privacy regulations.
ACKNOWLEDGEMENT: I have had the opportunity to review the contents of this authorization. By signing below, I am certifying my agreement with the statements made in this form and agreeing to the release of my protected health information as indicated on this form.