I understand that I may revoke any authorization granted above by written notice signed by me delivered to the Practice’s Privacy Official at the address stated below.
My authorization remains valid until revoked by me in writing.
I acknowledge receipt of the Practice’s Privacy Practices Notice effective September 23, 2013 regarding the Practice’s rights and obligations and my rights regarding my Protected Health Information.
I acknowledge that I understand that I have the right to request and receive clarifications, explanations or further information with regard to The Practice’s Privacy Practices through written request signed by me addressed to the Practice’s Privacy Official.
Neurological and Electrodiagnostic Institute of St. Louis, Inc
Attn: Privacy Official
14825 North Outer 40
Chesterfield, MO 63017