Release of Information

Patient Rights

• I have the right to revoke this authorization at any time by contacting our office.

• I may inspect or copy the protected health information to be disclosed as described in this document.

• Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.

• Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.

• I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.