• You may refuse to sign this authorization.
• Refusal will not affect your ability to obtain treatment or your eligibility for benefits through your care provider.
• You may revoke this authorization at any time. Revocation will take effect immediately.
• You have a right to receive a copy of this authorization.
By clicking “submit,” you acknowledge that your care provider will not disclose nor directly receive any money for the use of your health information provided for this program.