I understand that if the person or agency that received my information is not a health care provider or health plan covered by the HIPAA privacy regulations, the information described above may be redisclosed
I understand written notification is necessary to cancel this authorization and can be addressed to the department listed at the top of this form. I am aware that my cancellation will not be effective as to disclosures already made in reference to this authorization.
I understand Northern Virginia Pediatric Associates, P.C. may not condition treatment on my decision to sign this authorization. I understand that this disclosure may include information regarding my child/children medical health and/or mental condition.