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Consent and Authorization for Release of Health Information

2. 

4. REASON FOR RELEASING INFORMATION:
   Information obtained since the date of enrollment in the home visiting program by the home visiting agency may be shared with and stored by the Minnesota Department of Health (MDH). MDH and its contractors will use the information for administering and evaluating this and other federal, state, county and tribal programs. MDH may share certain information about Family Home Visiting (FHV) clients with other FHV providers for program administration purposes. The data will not affect your access to services.

   Information obtained since the date of enrollment in the home visiting program by the home visiting agency may be shared with and stored by the Minnesota Department of Health (MDH). MDH and its contractors will use the information for administering and evaluating this and other federal, state, county and tribal programs. MDH may share certain information about Family Home Visiting (FHV) clients with other FHV providers for program administration purposes. The data will not affect your access to services.

6. REPORTING:
   Permits submitting information required for reporting to funding sources.

   Permits submitting information required for reporting to funding sources.

8. Chisago County Public Health Nurse*
   -- Select One --BarbBethanyBrandieErinHeatherJenRushess

10. PERSONAL INFORMATION:

12. Last Name*

13. First Name*

14. Middle Name*

16. Address*

17. Date of Birth*
    Date of Birth

19. City*

20. State*

21. Zip Code*

23. Phone Number*

24. Email Address (optional)

26. Child 1 - Name*

27. Child 1 - Date of Birth*
    Child 1 - Date of Birth

29. Child 2 - Name

30. Child 2 - Date of Birth
    Child 2 - Date of Birth

32. Agency/Provider/Family/Other: Minnesota Department of Health Family Home Visiting Reporting System

34. Please select how you wish to participate in the information sharing.*

    1. I agree to full consent (includes name, address, and city)
    2. I agree to limited data (excludes: name, address, and city)
    3. I am opting out of providing information

36. Signing this form means that you understand the following:
    1) I am giving permission for the release and exchange of information on me and my child(ren) as listed; 2) I will be given medical help even if I do not give permission to share my information; 3) I may cancel this consent at any time by writing to any agency listed above; 4) A cancellation request does not apply to information already shared.

    1) I am giving permission for the release and exchange of information on me and my child(ren) as listed; 2) I will be given medical help even if I do not give permission to share my information; 3) I may cancel this consent at any time by writing to any agency listed above; 4) A cancellation request does not apply to information already shared.

38. I agree and consent to providing a digital signature.

40. Signature of Client or Legal Representative*

41. Date Signed*
    Date Signed

43. Relationship of Legal Representative to Client

45. This authorization for release of information automatically expires one year from the date of signature.
    A photocopy of this document shall be honored as the original.

    A photocopy of this document shall be honored as the original.

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47. Submit

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