I understand that I may revoke this authorization at any time by notifying Rum River Counseling, Inc. in writing. Revoking this authorization does not apply to information that has already been released under this authorization. I have the right to inspect or copy the health information to be disclosed. Information that goes to a health care provider or health plan covered by federal privacy laws will be protected by federal privacy laws. Rum River Counseling, Inc. cannot re-disclose any information from other persons or entities as protected by state or federal privacy laws. I do not have to sign this form. Treatment will still be provided to me if I do not sign this form. Payment for services is not contingent upon me signing this form, unless those services are for the sole purpose of creating personal information for a third party, such as insurance companies. A fee may be charged for retrieval and copying of records according to MN 144.335 and Federal Rule 164.521.