Release of Information Authorization

Release of Information Statement

I hereby authorize Atlas Counseling & Education LLC to release and/or exchange information related to my participation in the Victim Impact Panel (VIP) with the person or agency I have designated. This information may include verification of enrollment, attendance, progress, and program completion.

I understand that this authorization is voluntary and that I may revoke it at any time by providing written notice, except to the extent that action has already been taken based on this authorization. This authorization will remain in effect until the completion of the program unless revoked earlier.

I understand that this authorization does not permit the release of confidential clinical or therapeutic information without my specific written consent.

By signing below, I acknowledge that I have read and understand this authorization and give my consent for the release of information as described above.

Financial Responsibility

I understand that I am responsible for all fees associated with my participation in this program/class. All payments are due as outlined at the time of registration and must be paid in full in order to receive credit or a certificate of completion. I acknowledge that failure to complete payment obligations may result in suspension or termination from the program.

In the event of a payment dispute, chargeback, or financial claim initiated through a bank, credit card company, or legal entity, I authorize Atlas Counseling & Education LLC to provide any necessary documentation to respond to and resolve the dispute. This may include, but is not limited to, proof of payment, written communication, and signed agreements acknowledging my enrollment and payment responsibility. I understand that this disclosure is limited solely to information required to verify the legitimacy of the transaction and does not constitute a release of confidential therapeutic or clinical information.

By participating in this program, I acknowledge and agree to these financial terms.

Revocation

I understand that I may revoke this authorization at any time by submitting a written request to Atlas Counseling and Education LLC, except to the extent that action has already been taken based on this authorization.

Notice to Recipient

This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR Part 2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2.