I hereby authorize the Veterans Supplemental Support Network (VSSN), its Behavioral Health Navigation Team, and its Medical and Whole-Health Care Team to exchange, release, and obtain information relevant to my ongoing care, treatment, and coordination of services. This includes communication among internal VSSN departments, contracted professionals, and approved collaborating agencies providing services to me.

​

This authorization is intended to facilitate continuity and coordination of care by allowing appropriate personnel to share information necessary for the development and implementation of my treatment plan, navigation support, and referral follow-through. The information disclosed under this authorization may include medical and behavioral health records, case management notes, appointment history, progress summaries, treatment plans, or referral documentation.

​

This release does not include psychotherapy notes, unless I have completed a separate, specific authorization for their disclosure. Only the minimum necessary information will be shared to achieve the intended purpose.

I understand that VSSN and its staff will use this information solely for the purpose of supporting my access to behavioral health, medical, and social services, as well as to monitor my progress toward identified health and wellness goals.

My rights under federal and state law are fully protected. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the California Confidentiality of Medical Information Act (CMIA), and Missouri Revised Statutes §§191.656 et seq., my health information cannot be released without my permission except as otherwise permitted or required by law.

​

I understand that I have the right to refuse to sign this authorization. My decision not to sign will not affect my eligibility for services, treatment, or benefits. I may also revoke this authorization at any time by submitting a written notice to care@vetsupportnet.org. Revocation will not apply to information already released in reliance on this authorization prior to the receipt of my written notice.

​

Once my information has been disclosed, I understand that it may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations. However, VSSN maintains strict internal confidentiality policies, secure electronic systems, and privacy safeguards to protect all patient and client records in compliance with HIPAA and state requirements.

​

Unless I specify otherwise in writing, this authorization will automatically expire one (1) year from the date of my signature below. I may request a copy of this signed authorization for my records.