PATIENT AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
I may refuse to sign this authorization. My refusal will not affect my ability to obtain treatment.
The recipient may not lawfully further use or disclose the health information unless another authorization is obtained from me, or unless the use or disclosure is specifically permitted by law.
I reserve the right to withdraw or revoke this authorization, in writing, at any time, except to the extent that Dr. Levoy has already disclosed the information.
I have a right to receive a copy of this authorization.