Standard Release of Information

Individual Name: Date:

DATA PRIVACY I, hereby, authorize ZUMBRO HOUSE INC. to routinely release information, originating at the program to: those employees of ZUMBRO HOUSE INC. who have a need to know; the members of my Support Team; others involved in my services; my employer during the length of my use of the services; various Federal, State, or County agencies who have a right to the information by law; or ZUMBRO HOUSE INC. Internal Review Committee, who may need to review parts of my records routinely to assure that my legal rights are protected during the delivery of these services to me. I understand the purposes for collecting and releasing information originating at the program as described below. I also understand that the information released will be used only by those persons or agencies identified here. The Minnesota Government Data Practices Act protects your privacy, but also lets us give information about you to others if a law or government regulation requires it and we tell you before we do it. The information below tells why and when we will ask for and give information about you. It applies to all future contacts you will have with us. WHY DO WE ASK YOU FOR INFORMATION? We may ask you for information so we can tell you from other persons who get the same service; to decide what kind of services to recommend to your Case Manager; deliver those services in the most effective and efficient way possible; to work efficiently and effectively with other organizations or people who are also trying to help you; to protect your rights; collect money from the county, state, or federal government for the services we give you; to make reports, audit, and evaluate our services to make them better; and/or to make sure that our services are designed and delivered in accordance with all county, state, and federal laws and regulations. DO YOU HAVE TO ANSWER THE QUESTIONS WE ASK? Generally, the law says you do not have to give us all the information we ask for. However, some government laws and regulations require us to get some information. WHAT WILL HAPPEN IF YOU DO NOT GIVE US ALL THE INFORMATION WE ASK FOR OR ALLOW US TO SHARE WHAT WE DEVELOP WITH OTHERS WHO WORK WITH YOU? We need some information to give you services. If we do not get it, or if we cannot share it with others who work with you, then we might not be able to help you or our help might be late and not be much good. Also, we might not be following government laws or regulations, and may be ordered to get it later. We might also be fined for not having it. WITH WHOM MAY WE SHARE THE INFORMATION ABOUT YOU? We may give information about you that we develop from our services to: members of your Interdisciplinary Team, others who work with you; members of our staff who either work with you or who have a good reason to know; your employer(s); or members of our Internal Review Committee, but only enough to know if your rights are being protected. We may also have to give information about you to the following agencies, if they need it for investigations, or to help you, or to help us help you. This does not mean that we always share information about you with these people. It only says that there are laws that say we must share with them sometimes.  Minnesota Department of Human Services  Your County Social Service or Protection Units  The Ombudsman for mental health or mental retardation  U.S. Department of Health and Human Services  Social Security Administration  Various law enforcement agencies or officials  County, State, or Federal auditors  Your guardian, if you have one  School district/DT&H  Local or State Health Departments  Rep Payee YOU HAVE THE RIGHT TO SEE OR MAKE COPIES OF INFORMATION WE HAVE ABOUT YOU. You may review any information we keep on you, though we have at least five (5) days to get it ready. You may ask for copies, but you may have to pay for them. If you do not understand any of the information, you may have it explained to you. WHAT DO YOU DO IF YOU THINK THE INFORMATION WE HAVE IS WRONG? Your objections must be in writing and should be sent to the Director of Operations. You must write why the information is wrong/incomplete. You may send your own explanation of the facts you disagree with. Your explanation will be attached any time that information is shared with another agency. The release or use of this information for purposes or to agencies other than authorized here will not be made without my prior, written consent.

I understand that I also have the right to review any information which is maintained by ZUMBRO HOUSE INC. about me, as provided for in Chapter 13 of the Minnesota Data Privacy Act. I, further understand, that I may review the information before it is released, subject to my right to review this information under the controlling State and Federal laws. Yes No

APPROVAL TO EXCHANGE INFORMATION I authorize Zumbro House and those people and entities listed below to exchange information for the purposes of determining and providing services. Check those authorized and fill in specific names and entities on the lines provided. Place a line through any unused spaces.

Primary Clinic/Physician: Ophthalmology: Dental: Medical: Psychiatric: Psychological: Psychological: Social Services: Residential Program: Vocational/Work Program: Day Treatment Program: Pharmacy: Other: Other: Other:

I understand why I am being asked to release this information. I also understand that I may revoke this consent at any time or any part herein, except to the extent that action has been taken in reliance on it. In any event, this consent expires annually. I understand that my records are protected under privacy laws and cannot be disclosed without my written consent. I understand that I do not have to consent to release this information. If I do not consent, the information will not be released unless the law otherwise allows it. The person(s) or agency(s) that gets my information may be able to pass it on to others. If my information is passed on to others by this program, it may no longer be protected by this consent. I have participated in the completion of, and have been provided a completed copy of all pages of this Standard Release of Information. All or parts of this document can be amended upon written request, at any time.

______Individual Date

______Legal Representative Date

______Case Manager Date