I understand that by signing this form, I am requesting that the health information specified on this form be exchanged with the third party named on this form. I may stop this consent at any me by writing to the organization(s), facility(ies) and/or professional(s) named above. If the organization, facility or professional named above has already released health information based on my consent, my request to stop will not work for that health information. I understand that when the health information specified above is sent to the third party named above, the information could be re-disclosed by the third party that receives it and may no longer be protected by federal or state privacy laws. I understand that if the organization named above is a health care provider they will not condition treatment, payment, enrollment or eligibility for benefits on whether I sign the consent form.
This Consent will end one year from the date the form was signed unless I indicate an earlier date or event here: