Form Center

2. 
4. Chisago County Public Health Nurse*
   -- Select One --JenRushessBrandieJoy
6. I authorize Chisago County Public Health to exchange records and information containing private and protected health data about myself and my children for the purpose of coordinating care and ongoing public health nursing services.
8. For such purposes, I am requesting the exchange and release of information between Chisago County Public Health and the following organization:
10. Organization's Name:*
    Examples of Organizations: Health and Human Services (HHS), Medical Provider, Schools, Other
12. Type of Information (specify type):*

    1. General
    2. Financial
    3. WIC
    4. Medical
    5. Early Childhood
    6. Other
13. Other - Type of Information (Please detail):
15. Organization's Mailing Address:
17. Organization's City:
18. Organization's State:
19. Organization's Zip:
21. Organization's Phone:*
22. Organization's Fax:
24. In signing this consent, I understand that Chisago County is collecting private information about me and the children identified on this consent. The information collected through the exchange of information is private and will be shared and stored with Chisago County Public Health. I further understand that consenting to the release and exchange of information is voluntary and that opting out or withdrawing consent of the exchange and collection of information will not affect eligibility/participation in Family Home Visiting.
26. I understand that I have access to collected private data concerning me and the children identified in this consent. I may withdraw this consent through written notice at any time.
28. Parent/Legal Guardian - First & Last Name:*
29. Date of Birth:*
    Date of Birth:
31. I agree and consent to providing a digital signature.
33. Parent/Legal Guardian Digital Signature:*
34. Date Signed:*
    Date Signed:
36. Child's Name:*
37. Date of Birth:*
    Date of Birth:
39. 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.
Leave This Blank:


41. Submit

* indicates a required field