Diana Ponsford, DO

MY RIGHTS AS A PATIENT
I have a right to receive a copy of this Authorization in addition to the health information that I am requesting.

I may revoke this authorization at any time, but I must do so in writing. The revocation must be signed by me or on my behalf, and submitted to the following address: VCC, Attn: Medical Records, 465 La Tortuga Drive, Vista, CA 92081.

My revocation will take effect upon receipt, except to the extent that others have acted in reliance upon this Authorization.

If I have authorized the disclosure of my health information to someone not legally required to keep it confidential, it may be re-disclosed and may not be protected. California law prohibits the requestor from making further disclosure of my health information unless the requestor obtains another authorization from me or unless such disclosure is specially required or permitted by law.