This authorization will be in force and effect indefinitely. I understand that I have the right to revoke the authorization, in writing, at any time by mailing a letter to 462 Jackson Plaza, Ann Arbor, MI or emailing the front desk at [email protected].

I understand that a revocation is not effective to the extent that The Nutritional Healing Center of Ann Arbor has relied on the use or disclosure of the information I provided.

I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.

The Nutritional Healing Center of Ann Arbor will not condition my care, payment, enrollment in a health plan or eligibility for benefits (if applicable) on whether I provide authorization for the requested use or disclosure.

I understand that I have the right to inspect or copy the information I provided to be used or disclosed as permitted under federal law (or state law to the extent the state law provides greater access rights).

I understand that I am not required to sign this form and have the choice to decline.

The use or disclosure requested under this authorization will not result in direct or indirect remuneration to The Nutritional Healing Center of Ann Arbor from a third party.