Rights of the Patient
I understand that I have the right to refuse to sign this authorization and that my treatment will
not be conditioned on signing.
I understand that I have the right to revoke this authorization at any time by sending a written
notification to the address listed at the top of this form I understand that a revocation is not
effective in cases where the information has already been used or disclosed but will be
effective going forward.
I understand that information used or disclosed as a result of this authorization may be