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Refuah Health Center disclosed to a third party under this authorization could be redisclosed by that third party and no longer valid under this authorization.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.