Authorization for Access / Release of Information

I understand that: This authorization is valid for one year from the date of submission. I understand that after I have agreed to this form, I may change my mind and cancel (revoke) this authorization at any time by contacting HQ for Release of Information services. Cancellation of the authorization will not apply to information that has already been released based on this authorization. The information disclosed in response to this authorization may be subject to re-disclosure by the recipient, and will no longer be protected under the terms of this authorization. This authorization is voluntary and my records at HQ are in no way conditioned on whether or not I approve this authorization and that I may refuse to sign it. The parent or legal guardian must fill this authorization if the patient is a minor (under age 18).