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 Name* First Last Date of Birth*Today's Date*Other 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 or Individual*FacilityOther IndividualPlease choose whether your information is for a facility or other individual.Facility NameFacility Address Street Address City State / Province / Region ZIP / Postal Code Other Individual's Name First Last Other Individual's Phone NumberValid Time for ROIOne YearUnlimited Time (this ROI will not expire unless otherwise revoked by myself)Specific Time PeriodTime Period Start DateTime Period End DateValid Time Period for Records Being RequestedIf no specific date(s) are provided, only the most recent document(s) will be released for items that are checked.From Date Date Format: MM slash DD slash YYYY To Date Date Format: MM slash DD slash YYYY Specifically 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.Mental Health, Chemical Dependency, or Other Health Information Including the Following* Chemical Dependency Treatment Program Diagnostic Assessment/Comprehensive Evaluation Medication History CD Nursing Assessment Admission Information Functional Assessment Crisis Risk Assessment/Intervention Plan Primary Care Provider Notes Lab Results Chemical Dependency Program Discharge/Treatment Summary Medication Management Notes Treatment Plan Progress Notes LOCUS Legal Documents Other 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 Other 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 staff*YesNoWisconsin Privacy Regulations I understand that the client may also have a copy of the records requested above.Consent* I understand and consent to the following:• 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 ZVHC 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 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.EmailThis field is for validation purposes and should be left unchanged.
