**Please read, sign and date at the end of the document. **

My signature at the end of this document indicates receipt, review, and understanding of, and consent for, Effective Living Center, Inc, on the following documents: client bill of rights, Minnesota data practices act/HIPPA privacy rule, consent for maltreatment reporting. billing payer/insurance policy/release, telehealth policy, text messaging appointment reminders, and consent for treatment.

Client Bill of Rights/Client Rights Protection

It is the policy of Effective Living Center, Inc. to protect client rights and to follow the client bill of rights and healthcare bill of rights as required by section 148F.165, 144.651 and 253B.03 as applicable.

A copy of the client bill of rights shall be prominently displayed on the premises of the professional practice or provided as a handout to each client. The document must state that consumers of alcohol and drug counseling services have the right to:

1. Expect that the provider meets the minimum qualifications of training and experience required by state law.
2. Examine public records maintained by the Board of Behavioral Health and Therapy that contain the credentials of the provider.
3. Report complaints to the Board of Behavioral Health and Therapy for LADC, LPCC, ADC-T; You may report complaints by downloading the complaint form on their website: https://mn.gov/boards/behavioral-health/public/complaints-discipline.jsp. Please complete the form and mail it to the Board office at 2829 University Ave. SE, Suite #210, Minneapolis, MN 55414. If you prefer to have the form mailed to you, please call the Board office at (612) 548-2177.
   - For recipients of services by social workers, reports complaints to MN Board of Social Work at 335 Randolph Ave, Suite 245, Saint Paul MN 55102-5502, 612.617.2100 | 888.234.1320 | FAX 651.215.0956 Social.work@state.mn.us.
   - For recipients of services by psychologists, report complaints to Phone: 612-617-2230 Fax: 651-797-1372 Hearing/Speech Relay: 1-800-627-3529 Email: psychology.board@state.mn.us 335 Randolph Avenue, Suite 270, St. Paul, MN 55102
4. Be informed of the cost of professional services before receiving the services.
5. Privacy as defined and limited by the law and rule.
6. Be free from being the object of unlawful discrimination while receiving counseling services.
7. Have access to their records as provided in sections 144.92 and 148F.135, subdivision 1, except as otherwise provided by law.
8. Be free from exploitation for the benefit or advantage of the provider.
9. Terminate services at any time, except otherwise provided by law or court order.
10. Know the intended recipients of assessment results.
11. Withdraw consent to release assessment results unless the right is prohibited by law or court order or was waived by prior written agreement.
12. A nontechnical description of the assessment procedures; and
13. A nontechnical explanation and interpretation of the assessment results unless this right is prohibited by law or court order or was waived by prior written agreement.
14. Stereotyping: The provider shall treat the client as an individual and not impose on the client any stereotypes of behavior, values or roles related to human diversity.
15. Misuse of client relationship: The provider shall not misuse the relationship with a client due to a relationship with another individual or entity.
16. Exploitation of client: The provider shall not exploit the professional relationship with a client for the provider's emotional, financial, sexual, or personal advantage or benefit. This prohibition extends to former clients who are vulnerable or dependent on the provider.
17. Sexual behavior with client: A provider shall not engage in any sexual behavior with a client including: (1) sexual conduct, as defined in section 604.20, subdivision 7; or (2) any physical, verbal, written, interactive, or electronic communication, conduct or act that may be reasonably interpreted to be sexually seductive, demeaning, or harassing to the client.
18. Sexual behavior with a former client: A provider shall not engage in any sexual behavior as described in subdivision 6 within the two-year period following the date of the last counseling service to a former client. This prohibition applies whether the provider has formally terminated the professional relationship. This prohibition extends indefinitely to a former client who is vulnerable or dependent on the provider. Additionally, if the provider has a professional license that requires a longer period, then said license description of the most stringent time is utilized.
19. Preferences and options for treatment: A provider shall disclose to the client the provider's preferences for choice of treatment or outcome and shall present other options for the consideration or choice of the client.
20. Referrals: A provider shall make prompt and appropriate referral of the client to another professional when requested to make a referral by the client.
21. You have the right to reasonable notice regarding changes in counseling services or charges.
22. You have the right to complete current information concerning the counselor's assessment and recommended course of treatment, including expected duration of treatment.
23. You may expect courteous treatment and be free from physical, verbal, or sexual abuse.
24. Your records and transactions with the counselor are confidential unless release of these records is authorized in writing by you, otherwise provided by law.
25. You have the right to choose freely among available counselors, and to change counselors after services have begun, within the limits of available counselors.
26. You have the right to a coordinated transfer when there is a change in the provider of services.
27. You may refuse services or treatment, unless otherwise provided by law according to MN Statute 144.651
28. You may assert your rights without retaliation.

Minnesota Data Practices Act/HIPPA Privacy Rules: Information about your rights

Federal and State laws require that Effective Living Center, Inc. protect your privacy, to allow access to your file, to explain our need for and use of your personal information and to explain your rights regarding your personal information.

Federal law (HIPAA Privacy Rule) allows a mental health professional to share psychotherapy notes, at the provider's discretion, with client consent. In recognition of the sensitivity of this information, HIPAA requires that this consent be captured on a form only documenting the consent to release psychotherapy notes.

Minnesota law is more stringent than HIPAA with respect to the rights of individuals. In Minnesota, clients have the right to view or release all parts of their medical records and psychotherapy notes are part of that medical record that can be viewed or released. The added protection of the notes' inclusion in the medical record is to assure greater access for clients to all their protected health information.

HIPAA standard. Psychotherapy notes are specifically excluded from a client's general right to access or inspect their own medical records under HIPAA's Privacy Rule. If mental health professionals wish to disclose psychotherapy notes, they are generally permitted to do so, but must receive the client's authorization.

Minnesota standard. Minnesota's Health Records Act gives clients access to "complete and current information possessed by that provider concerning any diagnosis, treatment, and prognosis" and does not distinguish psychotherapy notes from other medical records.

HIPAA Standard: Right of Access. Under HIPAA's Privacy Rule, a mental health professional is not required to disclose psychotherapy notes to a client. In fact, psychotherapy notes are specifically excluded from a client's general right to access or inspect their own medical records. If a mental health professional ever wishes to disclose psychotherapy notes, however, they are permitted to do so, but must first receive the client's authorization (45 C.F.R. 164.524(a). There are only three instances in which a mental health professional does not need client authorization to use or disclose psychotherapy notes under HIPAA: Use by the provider for treatment; Use or disclosure for certain training purposes; or use or disclosure to defense in a legal action. (45 C.F.R.164.508(a)(2)).

Minnesota Standard: Client Access. Minnesota's Health Records Act gives clients broader rights when it comes to accessing mental health records because it does not distinguish psychotherapy notes from other medical records. Minnesota law requires that a provider give a client "complete and current" information concerning any diagnosis, treatment or prognosis that relates to the client upon request. (Minn. Stat. § 144.292, subd. 2). A client also has the right to access and consent to release records related to psychological services under administrative rules governing psychologists (Minn. R. 7200.4710).

Minnesota has created an exception, however, that gives providers the discretion to withhold health records (including psychotherapy notes) if the provider believes that "the information is detrimental to the physical or mental health of the client or is likely to cause the client to inflict self-harm, or to harm another." (Minn. Stat. 144.292, subd. 7).

Minnesota also has a "Duty to Warn" statute that places a provider under a duty to disclose protected statute information to "predict, warn of, or take reasonable precautions to provide protection from, violent behaviors." This duty arises when a client has communicated a specific, serious threat of physical violence against a specific, clearly identified, or identifiable potential victim. If this occurs, a provider must make reasonable efforts to communicate the threat to the potential victim or to law enforcement (Mn. Statute 148.975, subd. 2).

Some information we have on file at Effective Living Center, Inc. will be kept confidential, and cannot be seen by clients and are only accessible to government agencies that need the information. Information in this category includes civil or criminal investigations, some medical data, and the names of a person(s) who reports child or vulnerable adult abuse or maltreatment.

Your Access

You have the right to view your records or request copies, access may take 7 to 10 business days. Minnesota has created an exception, however, that gives providers the discretion to withhold health records (including psychotherapy notes) if the provider believes that "the information is detrimental to the physical or mental health of the client or is likely to cause the client to inflict self-harm, or to harm another." (Minn. Stat. 144.292, subd. 7). You may be required to pay for the cost of any requested copies.

Access by Effective Living Center, Inc. Staff and Other Agencies

Employees of Effective Living Center, Inc. will have access to your file, only when their work requires it. Others may have access to your file including attorney, insurance, and any other person who may become involved with legal or financial aspects of your file. By law, other agencies have access to certain aspects of your file if they provide a service to you or to Effective Living Center, Inc. These facilities include:

• Social Security Office
• U.S. Department of Health and Human Services
• The Minnesota Department of Health and Human Services/ Ombudsman for Mental Health & Mental Retardation
• Agencies with a valid court order
• County social service departments for investigation of abuse or neglect of minors or vulnerable adults.
• Coroner or Medical Examiner
• Attorney General
• Minnesota Department of Revenue or Internal Revenue Service

• To determine appropriateness of service. To make sure clients are being treated at the appropriate level of care.
• To allow Effective Living Center, Inc. to collect federal or state insurance funds for the services rendered at our facility.
• To prepare statistical reports and track outcomes.
• To audit Effective Living Center, Inc.'s program
• Other: Releases signed directly by you.

Client Rights

Right to file an appeal. You may speak directly with the Treatment Director (Ask staff if you need help with this) or write to: Commissioner of Administration, State of Minnesota, 50 Sherburne Avenue, St. Paul, MN., 55115.

Minors: If you are a minor, you have the right to request that private data about you be kept from your parents. You must make this request in writing. You must explain why you wish this data would be withheld and what you expect the consequences of sharing the data with your parents would be. If the agency agrees withholding the information from your parents is in your best interests, the data will not be shown to your parents.

Maltreatment Reporting:

By my signature, at the end of this document below, I acknowledge Effective Living Center, Inc, have a duty to warn obligation, are required to report the Maltreatment of Vulnerable Adult and/or Minors and give staff my permission, if it becomes necessary, to make a report to the Minnesota Adult Abuse Reporting Center as stated in Federal Regulations (42 CFR part 2) and/or local social services or law enforcement agencies, to protect vulnerable adults or minors. This release will remain in effect for one year from the date of signature. I have a right to revoke this authorization in writing at any time. Even if I do not give permission, the staff may still be required to report certain maltreatment issues.

Billing Payer/Insurance Policy and Release:

Individuals who have a third party (insurance) payer with a co-pay requirement, are required to pay the co-pay amount for services at the time of services. For clients who do not have a third-party payer, payment for services is due at the time of service and Effective Living Centers Office Administrator can provide current fee for service rate information.

Individuals who have a third party (insurance) payer with a deductible to be met, are required to make an initial payment of $350.00 at the time of intake and as a courtesy, Effective Living Center, Inc will submit the claim to the insurance carrier so that the cost may be applied towards the deductible. During the intake and orientation process, clients who have not met their deductible or have not made their co-pays at the time of service, will be asked to establish a payment plan for their program. Payment plans towards deductibles require a weekly minimum payment of $50.00.

Monthly statements will be provided to your billing address on file to keep you informed of any financial transaction, including insurance payments, occurring on your account. Should an overpayment occur, a refund check will be promptly provided to the authorized party due to the overpayment.

My signature at the end of this document authorizes Effective Living Center, Inc. to release my mental health and/or substance use disorder information electronically, on paper, or orally to my third-party payer(s), Medical Assistance, county of financial responsibility, insurance company, designated care management organization, prior authorization, etc.

I hereby authorize, from this day forward, any insurance company to whom I subscribe to pay directly to Effective Living Center, Inc. 821 W. St. Germain St. St. Cloud, MN. 56301, for services rendered to me or my dependents. I understand this consent remains in effect for one year and a photocopy of this benefit assignment shall be considered as effective and valid as the original.

I accept full responsibility for notifying Effective Living Center, Inc. immediately of any changes to any coverage while receiving care. If I provide insurance coverage information, I understand that my financial responsibility cannot be determined until my insurance company processes the claim and that submission of your insurance claim is a service the agency provides for you, and it is not a guarantee of third-party coverage. Failure to provide insurance coverage information will result in me being fully responsible for the bill. Statements of the client account are provided monthly to the client address on file.

I consent to the release of any information pertinent to my case to the insurance company/adjuster and authorize my provider to file a complaint to the Insurance Commissioner, for any reason, on my behalf. I understand the potential that information disclosed pursuant to this authorization might be re disclosed by the recipient and is longer protected by the HIPAA rules.

My signature below indicates that I accept financial responsibility for all charges not paid by my insurance for services provided to me or other individual that I serve as the guarantor/responsible party. I further understand if I do not attend a scheduled appointment and do not provide a 24-hour notice of cancellation or have an acceptable reason for the absence, the client may be charged for the absence and be solely responsible for the payment, unless elsewhere prohibited. For clients who do not have third party coverage for services, payment for service is due at the time of the appointment.

I understand that if I cannot pay my balance in full each month, I can request to set up payment arrangements. A 1.5% interest rate per month will be charged on unpaid balances. The annual interest rate is 18%. Additionally, if I become delinquent in my payments, I understand that future scheduled services may be cancelled, an alternate facility referral offered, and/or my account may be referred to an agency or court services for the purpose of collection.

Text Messaging Appointment Reminders:

My signature below authorizes my permission for Effective Living Center, Inc. to communicate with me appointment reminders via text messaging. I am aware of the limitations and potential risks that are related to my use of electronic communication including that use of electronic communication means that my confidentiality cannot be guaranteed according to HIPAA regulations. Furthermore, Withdrawing Authorization for text message reminders, MUST be in WRITING.

Telehealth Policy

Telehealth services are offered on a very limited basis to clients when it is more feasible than meeting in person with the provider. Some examples of feasible reasons for telehealth may include client or provider is experiencing an illness that may be communicable, weather conditions are hazardous for travel, client is incarcerated, provider is working from their home.

1. I understand that the information and client rights outlined in the Minnesota Data Practices Act/HIPPA Privacy Rule continue to apply to me during tele-therapy.
2. I understand that in some cases the information transmitted may not be sufficient due to deficiencies or failures of the equipment or internet connection.
3. I understand that the laws to protect privacy and the confidentiality of medical information also apply to telehealth and that no information obtained in the use of telehealth will be disclosed without my consent. Effective Living Center, Inc. has security and safeguards in place to protect such information; however, Effective Living Center, Inc cannot be responsible for any information that is disclosed on my end for lack of privacy at the location where I am receiving services.
4. I understand that disclosure of the location I chose to conduct therapy online is required and if the location changes, it is the client's responsibility to notify the provider to ensure compliance with State regulations. This is in place to ensure that appropriate emergency contacts/providers are accessible in the event of an emergency.
5. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but those results cannot be guaranteed or assured. Additionally, I understand that telehealth may not be as effective as face-to-face services and if my provider believes another form of services would better serve me; my provider may recommend/refer me to seek such services.

Attestation for Consent and receipt of documents:

My signature, below, at the end of this document indicates receipt, review, and understanding of, and consent for Effective Living Center, Inc, on the following documents: client bill of rights, Minnesota data practices act/HIPPA privacy rule, consent for maltreatment reporting. billing payer/insurance policy/release, telehealth policy, text messaging appointment reminders, and consent for treatment.

I further understand this consent remains in effect for one year and I must notify Effective Living Center, Inc., if I should want to withdraw any of these consents and authorizations.

I confirm and request services and care be furnished to me, the client, by Effective Living Center, Inc.

I accept that by signing below with a mouse, touch screen, or touchpad is the legal representation of my signature.