AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATIONINSTRUCTIONS 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. Client First NameClient Last NameDate of BirthToday's DateOther name(s) or identifying information under which personal health information (PHI) may be logged:I hereby authorize: Zumbro Valley Health Center, 343 Wood Lake Drive SE, Rochester, MN 55904 To: Exchange with Disclose to Obtain from Facility NameFacility Address Street Address City State / Province / Region ZIP / Postal Code Individual's Name First Last Individual's Phone NumberTime Period Start DateTime Period End DateMental Health, Chemical Dependency, or Other Health Information Including the Following Diagnostic Assessment Lab Results Medication History Alcohol/Drug Treatment Records Alcohol/Drug Assessment All information collected for State Medical Review Team Primary Care Provider Notes Psychological/Psychiatric Evaluation Therapy/Counseling Session Notes Discharge/Treatment Summary Medication Management Notes Treatment Plan Information about eligibility for MN Healthcare Programs Legal Documents Other (please specify)For the Following Purpose Determination of Disability Social Service Involvement At the request of the client Emergency Contact Billing Coordination of Care Court Ordered Continued Care/Treatment Planning Determine eligibility for healthcare benefits Other (please specify)Private Health Information (PHI) includes both written and oral Information. Do you give your permission for the facility or Individual to speak with ZVHC staffYesNoConsent* I understand and consent to the following:I understand that I may revoke this consent in writing at any time, as explained in ZVHC’s Notice of Privacy Practices. This authorization will automatically expire, without my express revocation, one year from the date of signature. However, any use or disclosure made in good faith prior to receipt of revocation shall be deemed valid. I also understand that any disclosure or use hereby authorized cannot be made to anyone other than the facility or individual listed above unless I provide such authorization. I understand that the information being disclosed by this authorization may be (re)disclosed by the recipient and no longer protected by the privacy regulation. 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 ZVHC or its providers based on whether or not I sign this authorization. Would you like a copy of this form emailed to you? Enter Email Confirm Email Enter your email and we will send you a copy of the form.PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
