SLMH Student ROI to DHS 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. Today's Date* Client Name* First Last Date of Birth* Email Enter Email Confirm Email 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*Please choose whether your information is for a facility or other individual. Facility Other Individual Facility Name Facility Address Street Address City State / Province / Region ZIP / Postal Code Other Individual's Name First Last Other Individual's Phone NumberValid Time for ROI* One Year Unlimited Time (this ROI will not expire unless otherwise revoked by myself) Specific Time Period Time Period Start Date Time Period End Date Valid 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 MM slash DD slash YYYY To Date 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. Chemical Health Psychotherapy Notes Mental Health or Other Health Information Including the Following* Diagnostic Assessment/Comprehensive Evaluation Psychological/Psychiatric Evaluation Medication History CD Nursing Assessment Admission Information Functional Assessment Crisis Risk Assessment/Intervention Plan Primary Care Provider Notes Lab Results 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* Yes No Wisconsin 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 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. NameThis field is for validation purposes and should be left unchanged.