CLIENT RIGHTS AND DATA PRIVACY INFORMATION

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.

Your Rights to Access and Protect Your Health Record

You have the following rights relating to your health record under the law:

1. You can see your health record for information about any diagnosis, treatment and prognosis.
2. You can ask, in writing, for a copy of summary of your health record, which must be given to you promptly.
3. You must be given a copy or a summary of your health record unless it would be determined harmful to your physical or mental health, or cause you to harm another.
4. You cannot be charged if you request a copy of your health record to review your current care.
5. If you request a copy of your health record and it does not include your current care, you can only be charged the maximum amount set by Minnesota law for copying your record.

Release of Your Health Record without Your Consent

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.

• Insurers and employers in workers’ compensation cases.
• Medical examiners or coroners
• Ombudsman for Mental Health and Mental Retardation
• Law enforcement agencies
• Health professional licensing boards/agencies
• Victims of serious threats of physical violence
• The State Fire Marshal
• Local welfare agencies
• Medical or scientific researchers
• Schools, childcare facilities, and Community Action Agencies to transfer immunization records
• Parent/legal guardian who did not consent for a minor’s treatment, when failure to release health information could cause serious health problems.
• Insurance companies and other payers paying for an independent medical examination.

CLIENT BILL OF RIGHTS

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:

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 335 Randolp Ave. Suite 290, St Paul, MN. 55102. Phone: 651-201-2756. Download form at: https://mn.gov/boards/behavioral-health/public-information/complaints-discipline.jsp
4. be informed of the cost of professional services before receiving the services; Effective Living Center has predetermined rates for all treatment services. These rates are based on private pay status, insurance contracts, and Behavioral Treatment Funds. Specific rates can be obtained from the office manager. The facility does not accept Medicare. Licensed staff is not able to accept partial payment for services or have fees waived.
5. privacy as defined and limited by 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 as 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 assessment procedures; and
13. a nontechnical explanation and interpretation of assessment results, unless this right is prohibited by law or court order or was waived by prior written agreement.

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:

1. sexual contact, as defined in section 604.20, subdivion 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.

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.

INFORMED CONSENT FOR AUTHORIZATION OF BENEFITS

I hereby instruct and direct my Insurance Company to pay by check made out to and mail to:

Effective Living Center, Inc., 821 West St. Germain St. Cloud, MN 56301

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.

• Prohibition of Re disclosure: This information has been disclosed to you from records whose confidentiality is protected under the Federal regulations governing Confidentiality and Drug Abuse Patient Records, 42 C.F.R, Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. pts 160 & 164. Federal Regulations prohibits you from making any further disclosures of this information except with the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations. A general authorization for the release of information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
• However, HIPAA requires ELC to notify me - the client - of the potential that information disclosed pursuant to this authorization might be re disclosed by the recipient and is longer protected by the HIPAA rules.
  
  For disclosures other than for treatment, payment and health care operations purposes, treatment may not be conditioned on my agreement to sign an authorization (unless I am receiving care solely to create protected health information for disclosure to a third party).

CONSENT FOR TELEHEALTH

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.

1. Purpose and Benefits: The purpose and benefit of telehealth visits is to provide more timely access to services. In addition to providing the clients convenience and timeliness to scheduling.
2. Client Safety OR Crisis management and interventions: Before engaging in telehealth services, we will develop an emergency response plan to address potential crisis situations that may arise during our telehealth work. We will need to have the address of your physical location and phone number. In the case of a mental health or psychiatric emergency during a telehealth session, where a client is deemed at imminent risk of harming themselves or someone else, ELC staff will contact the client’s local emergency services, crisis response team, and/ or 911.
3. Medical Information and Records: All existing laws regarding your access to medical information and copies of your medical records apply to telehealth services. Record requests or referrals for sending records to other agencies, such as probation offices, social services, attorneys’, other treatment, or medical facilities etc. can only be processed with a valid written Release of Information (ROI).
4. Confidentiality: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telehealth service. All existing confidentiality protections under federal and Minnesota states law apply to information disclosed during the telehealth visit.
5. Risks and Consequences: The telehealth service will be like a routine Mental Health/Substance use office visit, except with interactive video technology which will allow you to communicate with a provider at a distance. I understand that there are risks and consequences associated with telehealth, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, privacy, and/or limited ability to respond to emergencies. We will take reasonable steps to ensure your privacy. But it is important for you to make sure you find a private place for our session where you will not be interrupted.
6. Rights: You may withhold or withdraw your consent to telehealth services at any time without affecting your right of future care or treatment for ELC services.
7. Technical Difficulties: I understand that during a telehealth session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please call our office, St. Cloud 320-259-5381, or Little Falls at 320-632-3166 to discuss the issue as we may have to re-schedule.
8. Appropriateness of Telehealth services: It may be determined that telehealth services are no longer the most appropriate form of treatment for you. If this occurs, we will discuss other options such as in-person services with you.

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.

ACCEPTANCE

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.