This authorization shall expire 12 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 on the authorization. Refuah Health Center will not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization.
This authorization may include disclosure of information relating to Alcohol and Drug Treatment, Mental Health Treatment, and Confidential HIV/AIDS-related information only if I place my initials on the appropriate line above. In the event the health information includes any of these types of information, and I initial the line on the box above. I specifically authorize release of such information to the person(s) indicated above.
With Some exceptions, health information once disclosed may be re-disclosed by the recipient. If I am authorizing the release of HIV/AIDS-related, alcohol or drug treatment, or mental health information, the recipient is prohibited from re-disclosing such information or using the disclosed information for any other purpose without my authorization unless permitted to do so under federal or state law. If I experience discrimination because of the release or disclosure of HIV/AIDS-related information, I may contact the New York State Division of Human Rights at 1-888-392-3644. This agency is responsible for protecting my rights.