I understand that I may revoke this authorization at any time by giving written notice to Gerald Lewis Inc. However, I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.

I understand that under most circumstances a healthcare provider may not condition treatment, payment, enrollment, or eligibility for benefits on my signing this authorization. However, I understand that signing an authorization that permits the use and/or disclosure of my protected information for research purposes may be a condition of my treatment if I am undergoing research-related treatment. Also, I may be required to sign an authorization if my treatment is provided solely for the purpose of creating protected health information for disclosure to a third party. And under some circumstances, a health plan may condition my enrollment in a health plan or my eligibility for benefits on my providing an authorization permitting the health plan to make enrollment and eligibility determinations.

I understand that information used or disclosed pursuant to this authorization, except for Alcohol and Drug Abuse as defined in 42 CFR Part 2, may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations.

I have had the chance to read and think about the content of this authorization form and I agree with all statements made in this authorization. I understand that by signing this form, I am confirming my authorization for use and/or disclosure of the protected health information described in this form with the people and/or organizations named in this form.