7. I understand that I can revoke or cancel this authorization at any time by sending a letter to the Privacy Officer of the organization listed above and which is to supply this information. If I do this, it will prevent any releases after the date it is received but cannot change the fact that some information may have been sent or shared before that date.
8. I understand that I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment from the professional or facility listed at number 2 above, nor will it affect my eligibility of benefits.
9. I understand that I may inspect and have a copy of the health information described in this authorization. If I request a copy of this information, I understand I will be charged $20 for the first fifteen (15) pages and $0.90 for each additional page.
10. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be disclosed and no longer protected by those regulations
11. I understand that this professional or facility will receive compensation for the use or disclosure of my health information. The arrangement has been explained to me and I understand all of it. Does not apply
12.I affirm that everything in this form that was not clear to me has been explained and I believe I now understand all of it.