I understand that I have the right to take back this authorization, at any time, except when the release of records has already happened. I must submit this request in writing to the person who has my records. My removal of permission will not be effective until delivered in writing to the person who has my records. Information disclosed to someone who has received my records based on my permission can be re-disclosed by them and is no longer protected by federal privacy regulations. I understand that my health care and the payment for my health care will not be affected if I do not sign this form.
This permission will end 12 months from the date of signature unless an earlier date is requested.