I understand that this authorization is voluntary.
I understand that a health care provider may not condition treatment on whether I sign this authorization.
I understand that if the person(s) or organization(s) authorized to receive this information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations. To the extent that this information is required to remain confidential by federal or state law, the recipient of this information must continue to keep this information confidential.
I understand that I may revoke this authorization at any time by notifying the organization releasing this information in writing. If I do revoke this authorization, I understand it won't affect actions taken before my revocation was received.
I understand that I may request a copy of this authorization.