• 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 the button to the right you acknowledge that you understand that your care provider will not directly receive any money for the use and/or disclosure of the health information required for this service.