Terms & Contidions

  1. I understand that this authorization will expire in 90 days
  2. I understand that I may revoke this authorization at any time by notifying Healthy Living Clinic, LLC in writing, and it will be effective on the date notified except to the extend action has already been taken in reliance upon it.
  3. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by Federal privacy regulations.
  4. I understand that in compliance with Florida regulations I will pay the charge for copying clinic medical records is $1 per page up to 25 pages and 15 cents for each additional page.
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