HIPAA

I may revoke this authorization in writing at any time. If I do, it will not affect any actions already taken by Dr. Wolstein based upon this authorization. To revoke this authorization, I must write a letter to Dr. Wolstein. I understand that, if this information is disclosed to a third party, the information may no longer be protected by federal or state privacy laws and may be re- disclosed by the person or organization that receives the information. I release Dr. Wolstein, his employees and agents, medical staff members, and business associates from any legal responsibility or liability for the disclosure of the above information to the extent indicated and authorized herein.