I understand I have the right to revoke this authorization, in writing, at any time, except (1) where uses or
disclosures have already been made based upon my original permission or (2) the authorization was obtained
as a condition of securing insurance coverage and the insurer by law has the right to contest a claim or the
insurance policy. I understand that uses and disclosures already made based upon my original permission
cannot be taken back. To revoke this authorization, I must do so in writing and without my express
revocation, this consent will automatically expire 90 days from today’s date. I understand that it is possible
that information used or disclosed with my permission may be re-disclosed by the recipient and no longer
protected by the federal Privacy Standards.