This authorization is effective for no longer than 1 year from the date on which it was signed. (If left blank this document is good for 1 year from the signature date.) I understand that I may revoke this authorization at any time, except to the extent that action has already been taken in reliance upon it, by giving written notice to the Medical Records Department of the source facility. I understand that I have the right to inspect the information to be disclosed upon the proper notification to and under conditions established by the source facility. I understand that my health care and payment for my health care will not be affected if I do not sign this form. I understand this authorization is voluntary. I understand that if the recipient of this information is not a health plan or provider, the released information may no longer be protected by federal privacy regulations and may be subject to re-disclosure. I understand that I am entitled to receive a copy of this completed authorization form.

I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to DMOS’s Privacy Officer. Please refer to DMOS’s Notice of Privacy Practices. I understand that a revocation is not effective to the extent that DMOS has relied on the use or disclosure of the protected health information or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. DMOS will not condition my treatment, payment, enrollment, or eligibility for benefits on whether I provide authorization for the requested use or disclosure.