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  • Incoming Release of Information Authorization

    Use this form when you would like an outside facility or provider to send us your records.
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  • I authorize the following facility/facilities to disclose individually identifiable health information about me to:

    Refuah Health Center
    728 North Main St.
    Spring Valley N.Y. 10977
    845-354-9300 ext 1510

  • Periods covering:

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  • This authorization shall expire 6 months from the date of the request. This authorization may be revoked by me at any time by a written or verbal notice to Refuah Health Center, except to the extent that Refuah Health Center has relied o the authorization.
    Refuah Health Center will not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization.

    I understand that there is always the potential that information Refuah Health Center disclosed to a third party under this authorization could be redisclosed by that third party and no longer valid under this authorization.

    I further understand specific type of information to be disclosed may, if applicable include: Psychological Treatment, Diagnosis, Prognosis and treatment for Acquired Immune Deficiency Syndrome, Aids Related Complex, or Human Immunodeficiency infection for any date of service.

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  • Should be Empty:
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