SLMH Student ROI to DHS • Zumbro Valley Health Center

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.

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 Number

Valid 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 Requested

If no specific date(s) are provided, only the most recent document(s) will be released for items that are checked.

From Date

To Date

Specifically Requesting

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.

Chemical Health
Psychotherapy Notes

Mental Health or Other Health Information Including the Following*

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.

Name

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