HIPAA: I have a right to: (1) receive a copy of this signed authorization upon request; (2) refuse to sign this form/authorization; and (3) inspect or copy my information. CITC may not condition treatment, payment, enrollment in a health plan or eligibility for health care benefits on a decision to sign this form. I may arrange to inspect or copy information by contacting CITC. 42 CFR Part 2: Information used or disclosed under this authorization may be subject to re-disclosure and no longer protected under federal law. However, federal/state law may restrict re-disclosure of HIV/AIDS, mental health information, genetic testing information and drug/alcohol diagnosis, treatment, or referral information. Redisclosure notification is included with released information where appropriate. VAWA: Information covered by Violence Against Women Act may be disclosed and I understand the type of information, reason for sharing, and potential recipients authorized in this release under this release.