AUTHORIZATION TO SHARE PERSONAL HEALTH INFORMATION WITH FIND HELP Find Help is an electronic resource navigation tool to help providers find and refer you to services, programs, and community resources to help meet your needs. INSTRUCTIONS TO CLIENT OR THEIR PERSONAL REPRESENTATIVE: 1. Make sure all fields on this form are filled in. 2. Sign and date this form only if you believe the use and disclosure of information is in your best interest. Today's Date* MM slash DD slash YYYY Client's Name* First Last Is the Patient under 18 years old?* Yes No Parent/Guardian Name* First Last Email I authorize Zumbro Valley Health Center staff to share my personal health information with Find Help and community organizations listed on Find Help in order to receive additional services and support. I understand that only the minimum necessary information will be provided in order to receive such support and referrals, including name and preferred contact information. Find Help ROI Valid for:* One Year Specific Time Period Unlimited Time (this ROI will not expire unless otherwise revoked by myself) Specific Time Period*Please put in specific dates or years for desired time period.For the following purpose:* Select All At the Request of the Client Coordination of Care 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 further understand if there is a previous release on file for this individual/facility, it will remain in effect unless it is specifically revoked or has expired. CommentsThis field is for validation purposes and should be left unchanged.
