Records to be released: All records relevant to purpose of release.
I understand that:
I may revoke this authorization at any time in writing, except to the extent that action has been taken based upon it;
The recipient of these records may further disclose this information and it may then no longer be protected by federal privacy regulations;
I am entitled to a copy of this document;
I may refuse to sign this authorization and my refusal to sign will not affect treatment, payment, enrollment, or eligibility for benefits;
There may be a charge for the release of these records pursuant to 45 CFR 164.524 (c) (4) (HIPAA);
This authorization shall expire upon my written request to revoke or according to state law; A copy of this authorization is valid as the original.