Grievance/Privacy/Rights and Responsibilities • Zumbro Valley Health Center

Date*
MM slash DD slash YYYY
Client Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Name of Parent, Guardian, or Personal Representative
(if applicable)
First Last
Relationship to Client
Home Phone
Work Phone
Cell Phone
Email*
Enter Email Confirm Email
Documents Received*
I have received a copy of, read, and understand the following documents:
• Client's Rights and Responsibilities
• Notice of Privacy Practices
• Grievance/Complaint Procedure
• Missed Appointment Policy
Statement of Understanding*
I understand that if I have questions I can ask my counselor or another ZVHC staff person.
Communication Consent*
I authorize Zumbro Valley Health Center to contact me, whenever needed, for any reason pertaining to my services by:
Please select all that apply:*
- Select All
- Home Phone
- Work Phone
- Text
- Email