Term: This Authorization will remain in effect until PRIORITY URGENT CARE fulfills this request. Revocation: I understand that I may revoke this Authorization at any time by requesting it of PRIORITY URGENT CARE in writing at the address listed below. The revocation will be effective immediately upon PRIORITY URGENT CARE receipt of my written notice. I understand that the revocation will not have any effect on any action taken by PRIORITY URGENT CARE in reliance on this Authorization before it received my written notice of revocation. Mail written notice to: Priority Urgent Care 105 West Road, Ellington, CT 06029.
Effect on Treatment: I understand that I may refuse to sign this Authorization for any reason and that such refusal will not affect the commencement, continuation, quality or payment for such treatment at PRIORITY URGENT CARE.
Potential for Redisclosure: I understand that under applicable law the information disclosed under this authorization may be subject to further disclosure and thus, may no longer be protected by federal privacy regulations.
COPY FEE: Pursuant to HIPAA and CT regulation, we reserve the right to charge a reasonable cost-based fee for producing and mailing the copies.
