My refusal to sign this authorization will NOT affect my ability to obtain treatment, payment, or enrollment in a health plan. I understand I have the right to shorten the authorization period. I understand that I have the right to revoke this authorization at any time in writing, and that the revocation will be effective except to the extent that RCI has already taken action in reliance on my authorization. My written statement that I want to revoke my authorization should be delivered to:
Serenity-BHS, 623-H Park Meadows Road, Westerville, Ohio 43081
Attn: Medical Records Coordinator