I understand and acknowledge the following statements: I may be asked to show proof that I have the authority to sign this authorization. I may be charged a fee for any copies of my medical records or my child’s medical records in accordance with federal and state regulations. I have the right to revoke this authorization at any time. Revocation must be made in writing to: Cook Children's Health Care System, Health Information Management Department, 801 7th Avenue, Fort Worth, Texas 76104. My revocation will not apply to information that has already been disclosed in response to this authorization. After the above medical information is released, it may be re-released by the recipient and the information may no longer be protected by federal privacy laws or regulations.