I ACKNOWLEDGE AND UNDERSTAND:
I understand the expiration date of this authorization is one (1) year.
I understand that I may revoke this authorization at any time by notifying the providing organization in writing, and it will be effective on the date notified, except to the extent action has already been taken.
I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer be protected by Federal privacy regulations.
I understand by authorizing the use or disclosure of information, there will be no conditions placed on my health care or payment for my health care.
I understand that I may be required to pay a fee for retrieval and photocopying of records and/or supervising inspection of medical records.
I understand that my medical information may include information relating to sexually transmitted disease, sickle cell anemia, AIDS, HIV, behavioral or mental health services, and treatment for alcohol and drug abuse.
