HIPAA

1. Right to Revoke

• • I understand that I may revoke this authorization at any time by submitting a
    written request to Buffalo Rehab Group. Revocation will not apply to
    information already released based on this authorization.

2. Voluntary Authorization

• • I understand that Buffalo Rehab Group will not condition treatment,
    insurance enrollment, or eligibility for benefits on signing this form.

3. Potential for Re-Disclosure

• • I understand that information disclosed under this authorization may be re-
    disclosed by the recipient and may no longer be protected by HIPAA.