This authorization will expire upon the earliest of the following dates. 1)twelve months following date of signature on this form 2) the date the stated purpose is fulfilled 3)the date that I revoke this authorization at any time by writing a statement to the authorized releaser as noted above except to extent that life medical PA has relayed on the authorization.Aphotocopy or facsimile of the authorization shall be treated as valid as the origional.I understant that life medical PA will not condition treatment,payment,enrollment or eligibility forbenifits on whether I sign the consent form.I understand that once this information is disclosed ,it may no longer be protected under the federal privacy policy regulations and that the recipient might redisclose the information.