EXPIRATION: This authorization is for the duration of your pregnancy and through the second year two of your child, and will automatically expire upon your baby's third birthday.
MY RIGHTS: I may refuse to sign this authorization. My refusal will not affect my ability to obtain treatment of my eligibility for benefits at my hospital.
I may revoke this authorization at any time. My revocation will take effect immediately.
I have a right to receive a copy of this authorization.
REMUNERATION: I understand that my hospital will not directly receive any money for the use and/or disclosure of the health information required for this service.
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