_________ (Initial) I understand that I have the right to withdraw my authorization at any time except to the extent that action has already been taken pursuant to this authorization. I Understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Medical Records Department.
_________ (Initial) I understand that authorizing the disclosure of this health information is voluntary, I can refuse to sign, and future treatment, payment, or eligibility for benefits will not be based on whether or not I provide authorization for the requested use or disclosure. I understand that the recipient may be prohibited from disclosing substance abuse information. I understand that I may inspect or copy the information to be disclosed (with reasonable charge).
_________ (Initial) I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient of the information and is no longer protected by federal confidentiality laws. Unless otherwise revoked, this authorization will expire six months from the date of the signature listed below.
Patients Signature __________________________ Date ________________