Authorization/Consent for Treatment: I consent to the rendering of care which may include mental health and/ or chemical health services as my care team a consider to be necessary. I may be offered services via telemedicine systems that involve the delivery of care by electronic communication with a provider who is at a different physical location. I consent to initiating and/or receiving technology-based communications with my providers, including consulting services from a specialist performed virtually. I agree to be responsible for any charges that insurance does not pay. I understand that my care and treatment may be provided by clinicians, including clinical trainee's, interns, peer support specialists, mental health practitioners, nurse practitioner, nurses and other mental health care providers. I have read and understand this Authorization for Treatment and understand that no guarantee or assurance has been made as to the results that may be obtained. Per MN Statute 144.343 any minor may give effective consent for medical, outpatient mental services and other health services to determine the presence of or to treat pregnancy and conditions associated therewith, venereal disease, alcohol and other drug abuse, and the consent of no other person is required.
Authorization to Use and Disclose my Private Health Information**:
I consent that as a ZVHC client, my health Information will be used, processed, and
disclosed in accordance with U.S. law and as outlined in ZVHC's Notice of Privacy Practices (zvhc.org/npp). Furthermore, I authorize ZVHC to use, process, or disclosemy health Information:
• To provide me with treatment and to coordinate my care;
• To bill for and collect payment for services, which may include communications to my Payer(s)*** and Billing Addressee/Guarantor;
• For health care operations as described in the ZVHC Notice of Privacy Practices;
• For ZVHC and my insurer(s) to share my past, current, and future health, treatment and account records about services I have received from ZVHC as needed to manage or coordinate my care and improve the quality of that care;
• To accrediting and quality organizations, regulatory agencies, and public health reporting agencies;
• To participate in health record locator services/health information exchanges (HIE)/research programs that allow ZVHC, my health care providers, insurers and other third parties to electronically access and share my health Information via the HIE or research program unless I opt out. If I opt out, by checking the box below, ZVHC will exclude my ZVHC health information from the HIEs or research in which ZVHC participates.
Authorization for Photo in Electronic Medical Record:
• I authorize ZVHC staff to take my photograph and place a digital copy in my electronic medical record.
• I understand that ZVHC staff utilizes digital photos to familiarize themselves with clients, to confirm client identity, and to provide help if there is a need to locate a client in an emergency or crisis situation
• I understand that my photograph will be protected in the same manner as all other private information in my electronic record.
• I understand that refusal to consent to a photograph will not affect the services that I receive from ZVHC and its staff.
Authorization to Assign Benefits and Release Information: I authorize my Payer(s) to pay directly to ZVHC any benefits due under the terms of my health care plan(s), for services provided by ZVHC. I understand ZVHC reserves the right to refuse or accept assignment of medical benefits. If my health care plan(s) will not allow direct payment to ZVHC or if ZVHC chooses not to accept assignment of medical benefits. I agree to pay ZVHC all health care payments I receive for services. I authorize
ZVHC to contact my Payer(s) to obtain all pertinent financial information concerning coverage and payments made under my health care plan(s) and for my Payer(s) to release such information to ZVHC. I hereby give ZVHC authorization to appeal on my behalf for services provided at ZVHC. I understand that this may waive my insurance appeal rights as a member when appealing the insurance denial. By signing this form, I understand that future appeal and adjudication rights for services may be exhausted according to the provisions of my plan.
Service Terms
Statement of Financial Responsibility: I acknowledge I am responsible for all charges for services provided, including any amount not paid by my health care plan(s),
or an out of state payer, other than billing terms and restrictions under a government program or as prescribed by law in the state where services are provided. I authorize
ZVHC to apply any credit balance on my account to any amounts that I may owe to one or more ZVHC entities. I agree that ZVHC may obtain financial information,
including proof of income to determine eligibility for financial assistance and/or payment options. Information on financial assistance is available by calling 507-289-2089.
(where are we sending these calls) Dispute Resolution: I agree that any dispute (including personal injury claims) related to health care services rendered by ZVHC is
subject to the exclusive jurisdiction of the appropriate court in the state where the provider of the disputed services is physically located when the services are rendered and
the law of that state. Any state court action must be venued in the county where the provider of the disputed services is physically located when the services are rendered.
These agreements also apply to my legal representatives and next of kin.
Calling/Texting/Emailing: I agree that ZVHC may use an automated phone dialing system, pre-recorded or synthetic voice messages, texting, and email to contact me at the numbers and email addresses I provide. I understand that I may be contacted regarding my health care. This may include, but is not limited to, appointment reminders, discharge planning, billing, and/or to provide regulatory notice in lieu of first class mail. I understand that when contacted in this manner, I will be given the opportunity to opt out of similar future communications.
Notice of Privacy Practices: I acknowledge I have been presented with the ZVHC Notice of Privacy Practices, which can be viewed by clicking the link above this form.
Notice of Grievance/Complaint procedure: I acknowledge I have been presented with the ZVHC Grievance/Complaint procedure which can be viewed by clicking the link above this form.
Notice of Rights and Protection: I acknowledge I have been presented with the ZVHC Notice of Rights and Protections which can be viewed at zvhc.org, or I can also request a paper copy during my visit.
ZVHC Missed Appointment Policy: I acknowledge I have been presented with the ZVHC Missed Appointment Policy which can be viewed at ZVHC.org or I can also request a paper copy during my visit.
Attention: This is a legal document. Changes will not be accepted on this form. Questions or requests for alterations must be made by calling 507-289-2089. By signing, I
agree that I understand and accept the terms on this form. I understand I have the right to revoke the authorizations on this form at any time by notifying ZVHC in
writing, except to the extent that ZVHC has already taken action in reliance upon them. These authorizations will remain valid until I revoke them in writing
