Consent Terms

I may revoke my consent to release information at any time except to the extent that action will have been taken or information released prior to the revocation of my consent. This authorization form is valid until six (6) months from application date.

This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit further disclosure unless expressly permitted by written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part II.