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Zumbro Valley Health Center
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  • Mental Health
    • Adult Counseling
      • ARMHS
      • Substance Use & Recovery Services
    • Community Support
    • Depression & Anxiety Treatment
    • Integrative Healthcare & Wellbeing
    • Medication Management
    • Mobile Crisis & Stabilization
    • Residential Treatment Services
    • Support Groups
    • Telehealth
    • Veteran Services
    • Youth and Family Counseling
      • ADD/ADHD
      • Mood or Behavior Disorders
      • Trauma Treatment
      • Psychiatric Evaluation
      • School-Based Services
      • Substance Use & Recovery Services
  • Substance Use
    • Counseling
    • Detoxification
    • Drug Testing Services
    • DWI Education
    • Support Groups
  • 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
  • Resources
    • Classes & Groups
    • Types of Therapy
    • Teachers & Parents
    • Educational Videos
    • ZVHC Videos
    • FAQs
    • News
    • Annual Report

SLMH Student ROI to DHS

SLMH Student ROI to DHS

  • 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.
  • MM slash DD slash YYYY
  • 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.
  • • 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.

    • 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.
  • This field is for validation purposes and should be left unchanged.

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Zumbro Valley Health Center

507.289.2089

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  • Monday - Thursday - 7:30am - 7:00pm
  • Friday - 7:30am - 12:00pm
  • Emergency/Crisis Hotline 844.274.7472

© 2023 Zumbro Valley Health Center

Zumbro Valley Health Center