I acknowledge the information to be released may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus(HIV). My health record may also include information about behavioral or mental health services and/or treatment for alcohol and drug abuse. I understand that I have a right to revoke this authorization at any time by giving written notice to VITAE I.M.C. I understand the revocation will not apply to information that has already been released in response to this authorization, and the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. In the absence of a revocation this specific authorization expires one year from the date of signature. I understand once the above information is disclosed, it may be redisclosed by the recipient and that the released information may not be further protected by federal privacy laws or regulations. I understand authorizing the use or disclosure of the information identified above is voluntary. I need not sign this form to obtain healthcare treatment.