The above mentioned Protected Health Information may be subject to re-disclosure by the party receiving the information and may no longer be protected by the privacy laws. To the extent that this form authorizes the sale of your Protected Health Information, such as a disclosure will result in remuneration to the practice. By signing this form, you authorize Calais Dermatology Associates to use and disclose Protected Health Information about you for the reasons mentioned above. You have the right to revoke this authorization at any time. However, such a revocation shall not affect any disclosure we have already made in reliance on your prior authorization. Submit your revocation to the Privacy Officer.
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