I expressly and voluntarily authorize disclosure of the above medical record for the purposes stated above. I futher u nderstand that I am not giving permission for any disclosure other than described above. I understand that I may revoke this authorization at any time, except to the extend that action has already been taken on this authorization.

This authorization of release is in effect until ________, at which time this authorization to use or disclose Protected Health Information expires.
I understand that I have the right to revoke this authorization in writing by sending the notification to:
Attn: Medical Records Custodian - Callahan Clinic
120 E 100 S Suite 15A
St. George, UT 84790
Callahan Clinic will not condition my treatment payment on whether I provide authorization for the requested use or disclosure. I understand I have the following rights:

To inspect or copy the Protected Health Information to be sued or disclosed or to refuse to sign authorization.