Client Rights and Protection Grievance / Complaint Procedure Missed Appointment Policy Notice of Privacy Practices ZVHC Authorization, Consent, and Service Terms Attention: This is a legal document. By signing, you acknowledge that you have read, understand, and accept the terms below. You may revoke this consent in writing at any time, except to the extent Zumbro Valley Health Center (ZVHC) has already relied upon it. 1. Authorization and Consent for Treatment I consent to the rendering of care by Zumbro Valley Health Center (ZVHC), which may include mental health and/or chemical health services as determined necessary by my ZVHC care team. Services may be delivered in person or through telemedicine. I understand that care may be provided by licensed clinicians, nurse practitioners, nurses, interns, clinical trainees, fellows, peer support specialists, or other qualified professionals. No guarantees or assurances have been made as to treatment results. I have read this Authorization for Treatment and understand that no guarantee or assurance has been made as to the results that may be obtained. Per MN Statutes 144.341 to 144.347, minors are legally authorized to consent for specific medical, mental, substance use disorder, and other health services. When a minor legally consents to services the parents/guardians do not have access to the data without consent from the minor. 2. Use and Disclosure of My Health Information I authorize ZVHC to use, process, and disclose my health information in accordance with applicable federal and state law and ZVHC’s Notice of Privacy Practices, available at zvhc.org/npp. This authorization includes use and disclosure of my health information for the following purposes: Treatment, care coordination, and quality improvement Billing and payment, including communications with my payer(s) Healthcare operations, accreditation, regulatory, and public health reporting Participation in Health Information Exchanges (HIEs), the Rochester Epidemiology Project (REP), and approved research programs Communications about treatment alternatives, new or expanded ZVHC services, wellness programs, or health-related products ZVHC protects all information shared through these systems in compliance with federal and state privacy laws. 3. Assignment of Benefits and Release of Information I authorize direct payment to ZVHC from my health plan(s) for services provided. If my plan does not allow direct payment, I agree to pay ZVHC all healthcare payments I receive for services. I authorize ZVHC to obtain coverage and payment information from my payer(s) and to appeal claim denials on my behalf. 4. Financial Responsibility I acknowledge responsibility for all charges not paid by my plan(s) or as otherwise limited by law. ZVHC may apply credit balances to any amounts owed. I understand that ZVHC may request proof of income or financial information to determine eligibility for financial assistance. 5. Communications Consent I agree that ZVHC may contact me using text, phone (including automated dialing systems and prerecorded messages), email, or mail for purposes including, but not limited to: Appointments and scheduling Prescription updates Billing and account notices Discharge planning Regulatory notices Research opportunities Information about ZVHC programs, services, wellness events, and treatment alternatives I understand that I may opt out of future non-treatment communications at the time they are sent, such as by following unsubscribe instructions or notifying ZVHC. 6. Authorization for Photograph I authorize Zumbro Valley Health Center (ZVHC) staff to take my photograph for inclusion in my electronic medical record (EMR). This photograph will be used solely for identification, safety, and clinical documentation purposes and will not be used for marketing, public display, or any other purpose. I understand that this photograph is treated as protected health information (PHI) under HIPAA and stored securely within ZVHC’s EMR system. 7. Legal Provisions Dispute Resolution: Any disputes are subject to the jurisdiction of courts in the State of Minnesota and governed by Minnesota law. Revocation: I may revoke this authorization in writing at any time, except where ZVHC has already acted in reliance upon it. Notice of Clients Rights and Protection: I acknowledge I have been presented with the ZVHC Clients Rights and Protections which can be viewed at zvhc.org, or I can also request a paper copy during my visit. Grievance / Complaint Procedure : I acknowledge I have been presented with the ZVHC Grievance / Complaint Procedure which can be viewed at zvhc.org, or I can also request a paper copy during my visit. Notice of Privacy Practices : I acknowledge I have been presented with the ZVHC Notice of Privacy Practices 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. Legal Acknowledgment By signing below, I confirm that: I have read and understand this document I consent to all authorizations and agreements stated above I understand that I may revoke these authorizations in writing at any time, except where ZVHC has already relied upon them Client Name(Required) First Last Is the Patient under 18 years old?(Required) Yes No Parent/Guardian Name First Last If other than patient's signature, relationship to patientLegal Guardian or RepresentativeMotherFatherPlease choose best relationship to the client from the dropdown menu.Email(Required)
