Standard Authorization

Individual Name: Date:

FINANCIAL ASSISTANCE AGREEMENT

I, hereby, authorize Zumbro House, Inc. to undertake, as identified below, the following procedures CHECKED “yes” to assist or teach me in the management of my money and benefits.

I give permission to store funds in a safe and secure place when I am not using them. Yes No

I give permission for employees to help to manage/budget and handle CASH ON HAND Yes No

I give permission for employees to help to manage/budget and handle CHECKING ACCOUNT Yes No

I give permission for employees to help to manage/budget and handle a SAVINGS ACCOUNT Yes No

I give permission for employees to help to manage and handle CHECK/ATM/CASH CARD Yes No

I give permission for employees to help to manage and handle GIFT CARDS Yes No

I give permission to help complete or complete for me, any required INCOME REPORTING Yes No

I give permission for Zumbro House to act as Representative Payee Yes No

I give permission for Zumbro House to act as Authorized Representative Yes No

I give permission to limit funds to a specific amount without prior approval Yes No

Specific information regarding the limiting of funds, including limit amount: ______

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I give permission to store my property for safe keeping Yes No

Specific information regarding the property to be stored, including reason for safekeeping: ______

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I give permission to limit cash to be carried without having to keep receipts or records Yes No

Pocket cash limited to: ______

I give permission for ZumbroHouse, Inc to provide financial reporting upon request only Yes No

If no,

  • note frequency of requested financial reporting: ______
  • note itemized funds records to provide: Cash Checking Savings Gift Cards

AUTHORIZATION TO ACT IN A MEDICAL EMERGENCY

I authorize the supervisory staff from Zumbro House, Inc.to manage my services to obtain all or part of the emergency medical services as I have CHECKED below. I understand that these authorizations apply only in the event of a medical emergency and I cannot be quickly reached.I also understand that I may revoke these authorizations at any time.

Yes, see specifics below No

Emergency First Aid Paramedic Care Outpatient Care Lab Procedures Emergency Surgery Other:

Please describe any limitations to the authorizations checked:

MEDICATION ADMINISTRATION AUTHORIZATION

I, hereby, authorize staff trained by the program to provide medication setup and/or medication administration (prescription medications, including psychotropic medications and over the counter medications) or treatments ordered by a health care professional.

I, hereby, authorize staff trained by the program to provide medication assistance to promote self administration of medications and treatments.

I, hereby, authorize Zumbro House’s RN or LPN to administer injection medication(s) according to prescriber’s orders and written instructions.

I refuse to authorize staff trained by the program to administer medications (prescription and over the counter) or treatments ordered by my health care professional.

AUTHORIZATION FOR RELEASE OF PHOTOGRAPH

I, hereby, authorize the staff at Zumbro House Inc.to maintain and release a photograph of me for use in iCare and in

emergency situations.

Yes No

CAMERA and AUDIO AUTHORIZATION

I, hereby, authorize the staff at Zumbro House, Inc.to videotape/audiotape and remotely supervise my activities while on Zumbro House property. Video cameras may be located in any and all common areas of the property, except bedrooms and bathrooms.

Yes No

MEDAL PROGRAM CONSENT

The Zumbro House, Inc. Medal Program was designed to provide a positive and non-punitive approach to curbing maladaptive behaviors and encouraging pro-social behaviors. We must recognize that as we continue to strive to help people be successful in the community that a key part of that success hinges on positive behavior. Please check off the appropriate box below (check one box only).

I wish to participate in the Medal Program and have my name and number of safe days displayed in the common area.

I wish to participate in the Medal Program and NOT have my name and number of safe days displayed in the common area.

I do not wish to participate in the Medal Program.

SIGNATURES

I understand that I may revoke this authorization at any time or any part herein, except to the extent that action has been taken in reliance on it. All or parts of this document can be amended upon written request, at any time. In any event, this consent expires annually.I have participated in the completion of, and have been provided a completed copy of this Standard Authorizations.

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IndividualDate

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Legal RepresentativeDate

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Case ManagerDate