Visions 530 Southlake Boulevard, Suite A, North Chesterfield, VA 23236 Office 804-901-5628 Secure Fax (804)302-7967 www.visionsrva.com Patient Date of Birth (dd/mm/yyyy format) Is the patient a minor or under guardianship? * Legal Guardian Name if applicable * I, (patient or Guardian if applicable), authorize Visions to send and receive the following records to/from the following organization: * Organization Name * Treating Professional Name at the Organization * Organization Physical Address * Organization Telephone Number * Organization Fax Number * Visions Counselor Name * Kimberly Best Johnson, LPC, LMFT Angelo L. Cabrera, LPC Audrice V. Johnson, LPC, LSATP Ashley R. Melton, LPC I give my consent to release the following protected health information and records (Select all that apply) * I understand that this information may be protected by Title 42 (Code of Federal Rules of Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 45 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. I further understand that the information disclosed to the recipient may not be protected under these guidelines if they are not a health care provider covered by state or federal rules. I understand that this authorization is voluntary, and I may revoke this consent at any time by providing written notice, and after 1 year this consent automatically expires. I understand that I have a right to receive a copy of this consent. I understand I have a right to refuse to sign this consent.