Right to Revoke Authorization. You have the right to revoke your authorization to use or disclose health information, except to the extent that action has been taken in reliance upon your authorization. Your request must be in writing.
Right to Revoke Authorization. I understand that any information I have authorized to share under this Agreement will be secured by A+ Bookkeepers, Inc. I understand that I may revoke this authorization at any time, in writing, before the information has been released. I understand that I have a right to receive a copy of this authorization upon request. By signing this agreement, I acknowledge that I have carefully read, understand and agree to the above terms and conditions Taxpayer Signature Date: Licensed by (1) GA Dept. of Banking & Finance (2) GA Insurance Commissioner’s Office Commercial Check Cashing • Business Insurance • Business Funding • Business Legal Access • Workers Compensation • General Liability ATM & Xxxx Payment • Personal Small Loans • Retail Check Cashing • Auto Insurance • Renters Insurance Home Insurance Western Union Visa Debit Cards xxx.XxXxxxxxXxxxxx.xxx CREDIT REPORT AUTHORIZATION AND PRIVACY DISCLOSURE FORM The undersigned applicant borrower hereby consent(s) to allow River City Bank and A+ Loans, Inc. (and to the extent necessary A+ Financial Services, Inc. and A+ Bookkeepers, Inc. acting on behalf of A+ Loans) to obtain and use undersigned borrower’s credit report in order to further evaluate the credit worthiness of the undersigned as principal(s), and/or guarantor(s) in connection with the extension of credit under the Freedom Advance and/or the A+ Installment Loan with credit check. I, , (the undersigned) hereby authorize and instruct River City Bank and A+ Loans, Inc., or its designated representative A+ Financial Services, Inc. or A+ Bookkeepers, Inc. to obtain and review my credit report. My credit report will be obtained from a credit reporting agency chosen by A+ Loans, Inc. I understand and agree that A+ Loans, Inc. intends to use the credit report for the purpose of evaluating my financial readiness to obtain a loan and by ability and willingness to repay such loan. I understand that intends to use the credit report for the purposes of confirming my/our residency address, verifying other credit information, including past and present credit use, and evaluating whether my/our income is eligible to support the loan/advance for which I have applied.
Right to Revoke Authorization. I acknowledge and understand that I may revoke this authorization any time with respect to any Authorized Person or Authorized Recipient by notifying such Authorized Person or Authorized Recipient in writing or by email. A written revocation must be sent to 0000 Xxxxxxxxxxx Xxx XX, Xxxxx 000 Xxxxxxxxxx, X.X. 00000. A revocation by email must be sent to xxxx@xxxxxxxxxxxxxxxxxx.xxx Inability to Condition Treatment, Payment, Enrollment, or Eligibility for Benefits on Provision of Authorization: No Authorized Person or other covered entity may condition my treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization.
Right to Revoke Authorization. You have the right to revoke your authorization at any time only if it is in writing.
Right to Revoke Authorization. If you execute any authorization(s) for the use and disclosure of your PHI, you have the right to revoke such authorization(s), except to the extent that action has already been taken in reliance on such authorization.
