I UNDERSTAND THAT:

• I have been instructed as to what information will be released, the purpose and intended use of the released information, who will receive the information, and any known consequences of this release. The information to be released is private and any subsequent use and release is controlled under the Minnesota Government Data Practices Act (Minn.Stat.1982 Chap.13) • I understand that State and Federal privacy laws protect my records. My records can be released only if I give my written permission or if the law allows it. I may cancel this consent with written notice at any time, but this written notice will not affect information the agency has already requested or released. I understand that those who receive my records under this release may share it with others. I also understand that once the information is shared with others, it is no longer protected by this authorization. Further, I realize Southern Minnesota Behavioral Health cannot prevent the re-disclosure of records released as a result of this request and that the records may not be subject to privacy rule protections: therefore, Southern Minnesota Behavioral Health is released from any and all liability resulting from redisclosure. • I have the right to revoke this authorization at any time by giving written notice to SMNBH. I understand that I may revoke this consent upon written notice (not retroactive) and that the consent will automatically expire within one (1) year after the date of my signature. I understand that the revocation will not apply: 1) To information that has already been released in response to this authorization; or 2) to my insurance company as the law provides my insurer with the right to contest a claim under my policy. • I need not sign this authorization to receive services unless the services are court-ordered or are being created solely for a third party (i.e., consultation). • This authorization will permit two-way telephone communication and exchange of information by electronic methods. • I am entitled to a copy of this authorization once I have signed it, and I may review/request copies of information disclosed. A photograph or facsimile of this authorization is as effective as the original. • I have been informed of my right to refuse to release this information.

1407 S State St., New Ulm, MN 56073

Part 1 - Payment Plan Request

A payment plan with Southern Minnesota Behavioral Health may be available to you. A portion of your outstanding balance is required each month, in addition to payment for current services on your appointment days. Payment plans must provide for payment in full within six months or less of the service date. Appointments will continue to be scheduled only if payment on your plan and your current balance are up to date.

Part 2 - Uninsured Discount Request:

If you do not have health insurance, do not qualify for the assistance programs and your household income is less that $125,000.00 per year, you may qualify for an uninsured discount. Please attach a current tax return and a letter from your employer that proves you are not insured. If you are not employed, please attach documentation that you do not qualify for Medical Assistance or MN Care. Please note: No authorizations will be given prior to receiving the proper documentation.

I UNDERSTAND THAT:

• I have been instructed as to what information will be released, the purpose and intended use of the released information, who will receive the information, and any known consequences of this release. The information to be released is private and any subsequent use and release is controlled under the Minnesota Government Data Practices Act (Minn.Stat.1982 Chap.13) • I understand that State and Federal privacy laws protect my records. My records can be released only if I give my written permission or if the law allows it. I may cancel this consent with written notice at any time, but this written notice will not affect information the agency has already requested or released. I understand that those who receive my records under this release may share it with others. I also understand that once the information is shared with others, it is no longer protected by this authorization. Further, I realize Southern Minnesota Behavioral Health cannot prevent the re-disclosure of records released as a result of this request and that the records may not be subject to privacy rule protections: therefore, Southern Minnesota Behavioral Health is released from any and all liability resulting from redisclosure. • I have the right to revoke this authorization at any time by giving written notice to SMNBH. I understand that I may revoke this consent upon written notice (not retroactive) and that the consent will automatically expire within one (1) year after the date of my signature. I understand that the revocation will not apply: 1) To information that has already been released in response to this authorization; or 2) to my insurance company as the law provides my insurer with the right to contest a claim under my policy. • I need not sign this authorization to receive services unless the services are court-ordered or are being created solely for a third party (i.e., consultation). • This authorization will permit two-way telephone communication and exchange of information by electronic methods. • I am entitled to a copy of this authorization once I have signed it, and I may review/request copies of information disclosed. A photograph or facsimile of this authorization is as effective as the original. • I have been informed of my right to refuse to release this information.

Date, event, or condition upon which this consent expires: Click or tap to enter a date. (one year maximum)

Information released to Southern Minnesota Behavioral Health should be sent to:

1407 S State St., New Ulm, MN 56073 Phone 507-354-3181 Fax 507-388-3199