By signing this form, I understand and acknowledge that I may revoke this waiver at any time in writing. However, in cases where disclosures were already been made prior to revocation, I understand that such revocations may not be taken back.
Under the HIPAA Privacy Standards, I understand that parties who are not a party to this agreement may possibly redisclose the information.
I understand that this disclosure is not mandatory and I may choose not to sign this waiver. I understand this waiver may not be conditioned upon a treatment.
I understand that upon submission of this waiver, I will receive a copy. The copy that I receive shall be deemed an original.