I understand that I may revoke this authorization at any time
, except to the extent that action has already been taken in reliance upon it, by giving written notice to Harmony Autism Therapy's Medical Records Department. A revocation is not valid if (1) action was previously taken in reliance on this authorization, or (2) if this authorization was obtained as a condition for obtaining insurance coverage. I understand that I have the right to inspect the information to be disclosed upon the proper notification to and under conditions established by the source facility. I understand that my/my child's health care and payment for my/my child's health care will not be affected if I do not sign this form, depending on the plans requirements. I understand this authorization is voluntary. I understand that if the recipient of this information is not a health plan or provider, the released information may no longer be protected by federal privacy regulations and may be subject to re-disclosure. I understand that I am entitled to receive a copy of this completed authorization form upon written request.