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  • Mental Health
    • Adult Counseling
      • ARMHS
      • Substance Use & Recovery Services
    • Integrative Healthcare & Wellbeing
    • Depression & Anxiety Treatment
    • Youth and Family Counseling
      • ADD/ADHD
      • Mood or Behavior Disorders
      • Trauma Treatment
      • Psychiatric Evaluation
      • Substance Use & Recovery Services
    • Community Support
    • Crisis & Residential Services
    • Telehealth
  • Substance Use
    • Detoxification
    • DUI Education
    • Counseling
    • Drug Testing Services
    • Support Groups
  • Medication Management
    • ADD/ADHD
    • Anxiety & Depression
    • Bipolar Disorder
    • Obsessive Compulsive Disorder
    • Post Traumatic Stress Disorder
    • Schizophrenia
  • Your Visit
    • What To Expect
    • About Us
    • Locations
    • Insurance Accepted
    • Client Forms
    • Make A Referral
  • Providers
    • Meet The Team
    • Leadership and Staff
    • Licensing and Certifications
    • Make A Donation
    • Annual Report
  • Resources
    • Classes & Groups
    • Types of Therapy
    • Teachers & Parents
    • Video Resources
    • FAQs
    • News

Release Of Information

Release Of Information

Home ยป Release Of Information
  • AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

    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.
  • Please choose whether your information is for a facility or other individual.
  • Valid Time Period for Records Being Requested

    If no specific date(s) are provided, only the most recent document(s) will be released for items that are checked.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • The 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.
  • โ€ข 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.

    โ€ข I recognize that the protected health information used or disclosed according to this authorization may be re-disclosed by the recipient and ZVHC can no longer protect it.

    โ€ข 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.

    โ€ข I understand that I will not be denied services by ZVHC or its providers based on whether or not I sign this authorization.
  • AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

    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.
  • I hereby authorize Zumbro Valley Health Center, 343 Wood Lake Drive SE, Rochester, MN 55904 to exchange information with, disclose information to, and obtain information from MN Department of Health and Human Services.

    This authorization is valid for an unlimited amount of time and will not expire unless otherwise revoked by myself.

    The records to be released are School-Linked Mental Health Grant Funding Information for State Data, to be used for the purpose of billing.

     
  • โ€ข 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.

    โ€ข I recognize that the protected health information used or disclosed according to this authorization may be re-disclosed by the recipient and ZVHC can no longer protect it.

    โ€ข 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.

    โ€ข I understand that I will not be denied services by ZVHC or its providers based on whether or not I sign this authorization.
  • This field is for validation purposes and should be left unchanged.

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Zumbro Valley Health Center