This notice explains your rights that you have to access your health record, and when certain information in your health record can be released without your consent. This notice does not change any protections you have under the law.
You have the following rights relating to your health record under the law:
There are specific times that the law allows some health record information held by your provider to be released without your written consent. Some, but not all, of the reasons for release under federal law are:
Under Minnesota law, health record information may be released without your consent in a medical emergency, or when a court order or subpoena requires it. The following include some of the agencies, persons, or organizations that specific health record information may or must be released to for specific purposes, or after certain conditions are met:
The Departments of Health, Human Services, Public Safety, Commerce, Employee Relations, Labor & Industry and Education.
Effective Living Center has two locations and phone numbers. Location one is at 821 W. St. Germain, St. Cloud, MN. 56301. Phone number (320)-259-5381. Location Number two is at 103 6th St NE, Little Falls, MN. 56345. The phone number (320) 632-3166. Clients may contact either location to request to speak to a supervisor about a concern.
Client Bill of Rights: a copy of the client bill of rights that met the requirements of MN Rules part 4747.1500 (MN statute section 148F.165, subd. 2) is posted in a prominent location in the counselor(s) office(s).
Rights: All clients had the rights identified in Minnesota Statutes, 148F.165 and/or as applicable part 144.651 (residential) and/or 253B.03 (clients under commitment). Clients are provided with a written statement and it is reviewed with them during service initiation/intake. When service initiation is completed in person, the client initials to acknowledge the receipt/review of the statement.
Explanation of procedures: A client has the right to have, and a counselor has the responsibility to provide, a nontechnical explanation of the nature and purpose of the counseling procedures to be used and the results of tests administered to the client. The counselor shall establish procedures to be followed if the explanation is to be provided by another individual under the direction of the counselor.
Client bill of rights: The client bill of rights required by section 144.652 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:
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.
Misuse of client relationship: The provider shall not misuse the relationship with a client due to a relationship with another individual or entity.
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.
Sexual behavior with client: A provider shall not engage in any sexual behavior with a client including:
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 or not the provider has formally terminated the professional relationship. This prohibition extends indefinitely for a former client who is vulnerable or dependent on the provider. Additionally, if the provider has a professional license that requires a longer period of time then said license description of time is utilized.
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. A variety of therapy approaches are utilized by the staff. However, the primary theoretical approach to treatment utilized by this agency is Motivational Interviewing and Cognitive Behavioral. In other words, our thoughts affect our feelings, and behaviors.
Referrals: A provider shall make a prompt and appropriate referral of the client to another professional when requested to make a referral by the client. If you desire services not available at the agency, ask a staff person and they can assist you with the information.
This document has been reviewed with me; is posted in the office and I have received a copy. Additionally, I understand the contents and my signature below indicates my consent for treatment.
I hereby instruct and direct my Insurance Company to pay by check made out to and mail to:
for the professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. THIS IS DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment.
A photocopy of this assignment shall be considered as effective and valid as the original.
I also authorize/consent to the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case.
This informed consent of release of information will remain in effect for a period of one year.
I authorize a doctor to initiate a complaint to the Insurance Commissioner, for any reason on my behalf.
Effective Living Center (ELC) offers telehealth services using an approved, HIPAA-compliant, Zoom platform. This platform complies with Minnesota State Statutes and Center for Medicare and Medicaid Services (CMS) guidelines for telehealth services. The telehealth service model allows for the delivery of Mental Health Services (assessments and individual therapy) and Substance Use Assessments and/or individual substance use sessions. There may be times when your groups are held via zoom, but you will be notified of this if it should occur.
Telehealth services are offered to clients who are determined to be appropriate for telehealth services; have a barrier that prevent the client and the provider from meeting in the same physical location, who have access to a compatible electronic device (computer, phone, tablet) with internet connection with both audio and visual capabilities; and who agree to download the video conferencing software “Zoom” on their device.
Authorization: I have been advised of all the benefits, potential risks, and consequences of telehealth. I have had an opportunity to ask questions about this service and all my questions have been answered. I understand the written information provided above.
Text Reminder Consent/Disclaimer: By enrolling in text appointment confirmations, you are authorizing ELC to send text appointment reminders to you on your provided cell phone number. Text message charges from your cell phone provider may apply. By opting into our text message system, you are providing consent to use personal information to provide text appointment reminders/confirmation for the services available by ELC. The text messaging system is provided by ELC to our clients on an as-is basis. Included in the reminder may be information such as the agency name, your name, your provider and appointment dates and times. ELC is not liable for any delays that may be experienced during the transmission of any messages, as delivery is based on the speed and effectiveness of your wireless provider. I authorize ELC to send appointment reminders via text for the client named above.
For your convenience, you may complete forms in our office or electronically online.
My signature below indicates I have reviewed, understand and agree to the following documents: client rights and data privacy information, client bill of rights, informed consent for authorization of benefits and consent for treatment, including telehealth.
I accept that by signing below with a mouse, touch screen, or touchpad is the legal representation of my signature.