A. I understand that PHI may include records disclosed by health care providers and facilities that previously provided treatment to me.

B. I understand that PHI may include information and records protected under Federal Law (such as alcohol and drug abuse treatment) and/or State Law (such as mental health, AIDS, or HIV).

C. I understand that I may revoke this Authorization at any time. However, the revocation will not apply to PHI that has already been used or disclosed pursuant to this authorization. Contact the Compliance Officer to initiate the revocation process.

D. I understand my treatment by Genesis Healthcare Inc. is not conditioned upon whether I provide authorization for the requested use or disclosure of my PHI.

E. I understand that the information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and may no longer be protected under federal privacy standards.