I understand that I have the right to revoke this authorization, in writing,
at any time. I understand that a revocation is not effective to the extent that any
person or entity has already acted in reliance on my authorization or if my
authorization was obtained as a condition of obtaining insurance coverage and the
insurer has a legal right to contest a claim.
I understand that my treatment, payment, enrollment, or eligibility for
benefits will not be conditioned on whether I sign this authorization.
I understand that information used or disclosed pursuant to this
authorization may be disclosed by the recipient and may no longer be protected by
federal or state law.