Unless otherwise revoked, this authorization will expire in one (1) year from the day of the signature.
I understand that I may revoke this authorization (except to the extent that action was already taken in reliance on this signed authorization) at any time by notifying Starlight Pediatrics in writing.
I understand that I can refuse to sign this authorization and that my refusal will not affect my child/children’s ability to obtain treatment, or to process payments.
I may inspect or copy any information used or disclosed under this agreement.
I understand that if the person or organization that receives the information is not a health care provider or plan covered by federal privacy regulations, the information described above may be redisclosed and would no longer be protected by these regulations.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
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