I would like copies of my health information indicated in the section below sent from:
I understand the information released under this authorization may be re-released by the recipient.
This consent may be revoked at any time by writing to the address above, except for any actions that has already been taken in reliance upon it.
Unless otherwise stated this authorization will expire in 180 days from the date signed. Treatment, payment, or enrollment in a health plan will not be conditioned on signing this authorization for the covered entity’s own uses.