I understand that I have the right to revoke this authorization in writing by sending notification to the address above. I understand that when I revoke this authorization, it is not effective to the extent that the clinic had already relied on the use of disclosure of the Protected Health Information. I understand the protected Health Information released pursuant to this authorization might be re-disclosed by the party who receives that information and may no longer be protected by federal or state law. The clinic will not base my treatment or payment on whether I provide an authorization for the requested use or disclosure unless the provision of health care is solely for the purpose of creating Protected Health Information for disclosure to a third party. I understand that I have a right to inspect or copy the Protected Health Information to be used or disclosed. I understand that I have a right to refuse to sign this authorization. If you have any questions concerning this form, please contact the clinic manager.