Redisclosure: I understand that once my health care provider discloses my health information to the recipient identified above, my health care
provider cannot guarantee that the recipient will not redisclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.
Refusal to sign/right to revoke: I understand that I may refuse to sign or may revoke (at any time) this Authorization for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of my treatment by my health care provider.
Revocation: I understand that this Authorization will remain in effect until the term of this Authorization expires or I provide a written notice of
revocation to my health care provider’s Privacy Office at the address listed below. The revocation will be effective immediately upon my health care provider’s receipt of my written notice, except that the revocation will not have any effect on any action taken by my health care provider in reliance on this Authorization before it received my written notice of revocation.