Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Enter Email Confirm Email Advance DirectiveAdvance directives are written instructions regarding your medical care preferences. Your family and doctors would consult your advance directives if you were ever unable to make your own health care decisions. A mental health directive is narrower in scope and pertains specifically to mental health treatment.Do you have an advance directive or a mental health directive? Yes No If you have an advance directive, may we have a copy? Yes No Copy received If you have a mental health directive, may we have a copy? Yes No Copy received Would you like to receive additional information on advance directives? Yes No Advance Directive Consent* I understand that advance directives and mental health directives are legal documents. In accepting this advance directive form, I understand that Zumbro Valley Health Center is not qualified to give legal advice and will not be held liable for decisions made in completing this document.Epidemiology Research AuthorizationEpidemiology Research Consent*Yes, I authorize Zumbro Valley Health Center and its research partners to use my medical records for research.No, I do not authorize Zumbro Valley Health Center and its research partners to use my medical records for research.Release of InformationAuthorization to Disclose Protected Health InformationOther name(s) under which personal health information (PHI) may be loggedPrevious names, aliases, etc.I hereby authorize Zumbro Valley Health Center to:Zumbro Valley Health Center 343 Wood Lake Drive SE Rochester, MN 55904 Phone: 507-289-2089 Select All Disclose to Exchange with Obtain from Facility NameOther Facility Name and Phone NumberOther Individual Name and Phone NumberEmail Enter Email Confirm Email Is this email encrypted? Yes No I understand the risk and request unencryptedI understand by choosing unencrypted email that the information being sent to Zumbro Valley Health Center could be visible to others and is not secure. Yes No Valid For For this specific time period One Year Unlimited Time The Release of Information is good for this specific time periodUnlimited Time Consent I understand that by choosing the unlimited option that this Release of Information will not expire unless otherwise revoked by myself.Please indicate the time period for which you are requesting recordsIf no specific date(s) are provided, only the most recent document(s) will be released for items that are checked.Requesting records from this dateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920To this dateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Specifically RequestingThe following information requires special consent by law. Even if you indicate all health information, you must specifically request the following information in order for it to be released. Chemical dependency Psychotherapy notes Mental Health, Chemical Dependency, or Other Health Information Including the Following Diagnostic Assessment/Comprehensive Evaluation Progress Notes Medication History Medication Management Notes Treatment Plan Psychological/Psychiatric Evaluation Discharge/Treatment Summary Chemical Dependency Program Lab Results Other Admission Information CD Nursing Assessment Crisis Risk Assessment/Intervention Plan Functional Assessment LOCUS Legal Documents Primary Care Provider Notes Other Information (please specify)For the Following Purpose Determination of Disability Coordination for Care At the Request of the Client Continuing Care/Treatment Planning Social Services Involvement Court Ordered Emergency Contact Other Billing Other Purpose (please specify)Do you give permission for the facility or individual to speak with Zumbro Valley Health Center staff?Private health information (PHI) includes both written and oral information.YesNoWisconsin Privacy Regulations I understand that the client may also have a copy of the records requested above.Consent and Authorization*I understand that I have the right to revoke this authorization. If Zumbro Valley Health Center has already released information based on this consent, we cannot retrieve what has already been released. I recognize that the protected health information used or disclosed according to this authorization may be re-disclosed by the recipient and Zumbro Valley Health Center can no longer protect it. I understand that the information to be released may include records related to behavioral and/or mental health care, alcohol and drug abuse treatment, and HIV/AIDS. I understand that I will not be denied services by Zumbro Valley Health Center or its providers based on whether or not I sign this authorization. I understand and give my consent.
