I have read and understand the following:
I may revoke this authorization at any time by submitting a
written request to the Privacy Officer at email@example.com
or by mail at Privacy Officer, 607 Dewey Ave NW, Ste 300, Grand Rapids, MI 49504.
I may refuse to sign this authorization. If I refuse to sign this
authorization, my treatment, payment, health plan enrollment, or eligibility
benefits will not be affected.