The purpose of the disclosure/communication is Coordination of Care.

Information to be used/disclosed consists of mental healthcare information, including (check all that apply):

I understand that additional laws about mental health, HIV/AIDS, genetic, and alcohol/drug treatment information may apply. I understand and agree that this information WILL BE DISCLOSED if I check any or all of the following boxes (Please check all that apply).

To be compliant with HIPPA, we must have your written consent to release any of your mental health records to ANYONE.

Please list any additional names, phone number, and relationship you give permission to have your records released to, if needed (if applicable):

I understand that I am not required to sign this authorization. If I refuse to sign this, it will not prevent me from receiving mental health treatment at Victory Counseling, LLC/Victory Counseling, LLC/Victory Behavioral Health, Inc. The only exception is if the services I am seeking are only for providing health information to someone else and this authorization is needed to make the disclosure.

I may revoke this authorization in writing at any time. If I revoke this authorization, the information described may no longer be used or disclosed for the reasons described here. I understand that the information used or disclosed as a result of this authorization may be subject to re-disclosure and no longer protected under federal law. 

Unless revoked, this authorization expires 1 year after the date signed or 60 days after the completion of treatment.

Signature - I understand and agree that this document, in its ENTIRETY, may be executed by electronic signature, and that the signature appearing below is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.