Authorization/Revocation

This authorization will terminate in one year unless otherwise specified. I may revoke this authorization at any time by notifying the releasing organization in writing. It will be effective on the date notified except to the extent action has already been taken. This authorization is valid for records prior to and after the date signed. Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by Federal Privacy standards. Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this authorization. In compliance with MN Statute 144.33, I may be required to pay a fee for retrieval and photocopying of records and/or supervising inspection of medical records. I may receive a copy of the signed authorization upon request. A photocopy or fax of this document is valid as the original. Twin Cities Pain Clinic will not release medical records obtained from another health care provider or facility.