Consent for Release of Information

I hereby authorize Vantage Point Behavioral Health LLC to release confidential information to the individual(s) or organization(s) listed below:

Your Rights

I understand that:

• I have the right to revoke this authorization at any time by submitting a written request to Vantage Point Behavioral Health LLC
• Revocation will not affect information already released under this authorization
• I have the right to refuse to sign this authorization
• My treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization
• Information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations
• I may inspect or copy the protected health information to be disclosed as provided by federal privacy regulations