CLIENT RIGHTS
When a provider works under a supervisor, their work is reviewed and signed off by a licensed provider. OPTUM/UBH does not credential these providers; however, THEIR SUPERVISOR IS, AND YOU CONSENT TO THE UNLICENSED PROVIDER NOT CREDENTIALED.
Consumers of psychological services or marriage and family therapy services offered by Psychologists, Marriage and Family Therapists, or Licenses Social Workers or Licensed Professional Clinical Counselors licensed by the State of Minnesota have the following rights:
To expect that a therapist has met the minimal qualifications of training and experience required by state law.
To examine public records maintained by the Licensing Board or Boards that contain a therapist's credentials.
To obtain a copy of the Code of Ethics or Rules and Conduct from the appropriate Licensing Board or Boards
To report complaints to the appropriate Licensing Board by writing or calling: Minnesota Board of Psychology - 2829 University Avenue SE, Suite 320, Minneapolis, Minnesota 55414. Phone: (612) 617-2230; and/or b) Minnesota Board of Marriage and Family Therapy -2829 University Avenue SE, Suite 330, Minneapolis, Minnesota 55414. Phone: (612) 617-2220; c) State of Minnesota Board of Social Work 2829 University Avenue SE, Suite 340, Minneapolis, Minnesota 55414. Phone: (612) 6172100, d) Minnesota Behavioral Board of Health and Therapy 2829 University Ave SE Suite 210, Minneapolis, MN 55414 (612) 617-2178.
To be informed of the cost of professional services before receiving the services
To privacy as defined by rule and law
To be free from being the subject of discrimination based on race, religion, gender, or other unlawful category while receiving services
To have access to their records as provided in Minnesota Statutes, section 144.335, subdivision 2
To be free from exploitation for the benefit or advantage of a therapist.
To refuse treatment at any time.
Confidentiality: Information a client shares with a therapist is confidential, except where otherwise specified by law. Information pertaining to a client's record or identity cannot be released to any individual or agency outside of Fuller Living & Associates, LLC, without the client's written consent. For best practice, case consultation will occur within Fuller Living & Associates, LLC.
Fuller Living & Associates will use email to communicate between offices and clients, which will entail some risk.
By law, if the therapist determines that the safety of the client is in question or that the client has plans to harm any other person(s), the therapist must make a report to the proper authorities and the person(s) mentioned, if appropriate. Also, if the client discloses any information that could be interpreted as physical or sexual abuse to a child or vulnerable adult, the therapist is required to make a report to the proper authorities.
A court of law may also require clinical records without a client's consent.
Fuller Living reserves the right to use a collection agency to collect overdue payments.
The client authorizes payment of benefits to Fuller Living & Associates, LLC for services rendered to the client or dependents.
The client authorizes the release of the required information to my insurance company.
Benefits quoted from insurance companies are not a guarantee of payment. If the insurance company does cover service costs, the client is responsible.
Privacy Practices
Fuller Living & Associates, LLC NOTICE OF HIPAA PRIVACY PRACTICES
Client Privacy Statement: This Notice informs you of how your medical information may be used and disclosed and how you can access this information. Please review it carefully and ask questions if needed.
This Notice is effective August 1st, 2015, and governs our practices on and after that date. Fuller Living & Associates, LLC and its contractors are required to protect the privacy of your Protected Health Information (PHI). We are required by the Health Insurance Portability and Accountability Act (HIPAA) to provide you with a notice of our legal obligations and privacy practices concerning PHI.
The terms we, our, and us refer to (Fuller Living), and the terms you and your refer to the client. This Notice of Privacy Practices describes how we may use and disclose your PHI to carry out treatment, payment, health care operations, and other purposes specified by law. We reserve the right to change this Notice. The changes will apply to the PHI we already have about you and the PHI we receive about you in the future. We will provide you with an updated notice if you request one. If you have questions about this Notice, our privacy practices, or the Fuller Living services this Notice applies to, please contact us at 763-647-8188 or speak with your therapist directly.
Protected Health Information Protected Health Information (PHI) is: 1. Information about your mental or physical health, related health care services, or payment for health care services. 2. Information that you provide, created by us or shared with us by related organizations. 3. Information that identifies you or could be used to identify you, such as demographic information, address & phone number, social security number, age, date of birth, dependents, and health history.
Except as described in this Notice or specified by law, we will not use or disclose your PHI. We will use reasonable efforts to request, use, and disclose the minimum PHI necessary. We will de-identify you or encrypt your personal information whenever possible so that you cannot be personally identified. We have put physical, electronic, and procedural safeguards in place to protect your PHI and comply with federal and state laws.
Your Rights: You have the following rights concerning your PHI. You may obtain a copy of this Notice at any time. Even if you have agreed to receive the Notice electronically, you are still entitled to a paper copy. You may ask us not to use or disclose any part of your PHI. Your request must be in writing and include what restriction(s) you want and to whom you want the restriction(s) to apply. We will review and grant reasonable requests but are not required to agree to any restrictions. You have the right to inspect and get a copy of your PHI as long as we maintain the information. You must put your request in writing. We may charge you for the costs of copying, mailing, or other necessary supplies to grant your request. We do have the right to deny your request to inspect and copy. If you are denied access, you may ask us to review the denial.
If you feel your PHI is incomplete or incorrect, you may ask us to amend it. You may ask for an amendment as long as we maintain the information. Your request must be in writing, and you must include a reason that supports your request. In certain cases, we may deny your request. If we deny your request for amendment, you have the right to file a statement of disagreement with our decision.
You have the right to receive a list of the disclosures (an accounting) we made on your PHI. The list will not include disclosures that we are not required to track, such as disclosures for treatment, payment, or health care operations; disclosures that you have authorized us to make; disclosures made directly to you or friends or family members involved in your care; or disclosures for notification purposes. Your right to receive a list of disclosures may also be subject to other exceptions, restrictions, and limitations. Your request for an accounting must be made in writing, and you must state the period for which you would like us to list the disclosures. We will not include disclosures made more than seven years before the date of your request. You will not be charged for the first disclosure list you request, but you may be charged for additional lists with the same 12-month period as the first.
You may ask us to communicate with you using alternative means or locations. For example, you may ask us to contact you about medical records only in writing or at a different address than the one in your file. Your request must be written in writing, and you must state how and when you would like to be contacted. You do not have to tell us why you are making the request, but we may require you to make special arrangements for payment or other communications. We will review and grant reasonable requests but are not required to agree to any restrictions.
Psychotherapy notes a psychotherapist writes during a counseling session are considered PHI. If those notes are kept separate from a client's medical records, HIPAA requires that they be treated with higher standards or protection than other PHI.
Common reasons for our use and disclosure of PHI include treatment, providing, coordinating, or managing health care and related services for you, and ensuring you receive appropriate and effective care. For example, we may contact you to provide appointment reminders, information about treatment alternatives, or refer you to other health-related benefits and services that may interest you. We might also contact another healthcare provider or third party to share information and consult with them about the services we are providing to you. We may use and disclose PHI to obtain payment or reimbursement for services. For example, we may need to disclose PHI to determine eligibility for treatment or claims payment. Additionally, we may use and disclose PHI to assist in carrying out administrative, financial, legal, and quality improvement activities necessary to our business and to support the core functions of treatment and payment.
Our business associates perform some healthcare administration and operation activities for us. Examples of our business associates include our billing service and claims administrators. We may disclose PHI to our business associates so that they can perform the job we have asked them to do. We require our business associates to sign agreements that limit how they use and disclose PHI. We require them to protect PHI and to follow our privacy practices.
We may disclose PHI to a group health plan administrator, who may, in turn, disclose such PHI to the group health plan sponsor solely to administer benefits provided by Fuller Living.
We may disclose your PHI to a family member, other relative, close personal friend, or any person you identify who is, based on your judgment, believed to be involved in your care or payment related to your care. Before disclosing PHI, we will ask you to complete a Release of Information for these individuals.
We must disclose PHI about you when required to do so by law. Less common reasons for using and disclosing PHI include legal proceedings. We may disclose PHI for a judicial or administrative proceeding in response to a court order, written Notice, or protective order. Fuller Living will not release PHI pursuant to a subpoena.
To avert serious threats to public health and safety. We may disclose PHI to avoid a serious and imminent threat to your health or safety or the health or safety of others.
We may disclose PHI to armed forces personnel under certain circumstances and to authorized federal 'Officials for national security and intelligence activities, including protective services for the President and other Heads of State.
Disclosures may be used to verify your eligibility for health care and enrollment in various health plans and to assist us in coordinating benefits for those with other health insurance or eligibility for government benefit programs.
We may disclose PHI to comply with worker's compensation laws and other similarly legally established programs.
We may disclose PHI to a person or company the Food and Drug Administration requires to report adverse events or product defects or problems, track products, enable product recalls, make repairs and replacements, and monitor post-marketing as needed.
We may disclose PHI to a public health authority permitted by law to receive the information for public health activities. This disclosure might be necessary to prevent or control disease, injury, or disability.
We may make disclosures to government authorities or social service agencies as required by law in the reporting of abuse (financial, emotional, physical, sexual, or verbal) and neglect. To government agencies for compliance purposes. We may use or disclose PHI to the Secretary of Health and Human Services to assist with a complaint investigation or compliance review.
We may use or disclose PHI, as authorized by law if you are an inmate of a correctional facility.
We may disclose PHI to law enforcement officials to identify or locate a suspect, witness, or mission person or to provide information about victims or crimes.
We are required to get your written permission (authorization) before using or disclosing your PHI for purposes other than those provided above or as otherwise permitted or required by law. If you do not want to authorize a specific request for disclosure, you may refuse to do so without fear of reprisal. If you provide your written authorization and later wish to withdraw it, you may do so in writing at any time. As soon as we receive your written revocation, we will stop using or disclosing the PHI specified in your original authorization, except to the extent that we have already used it based on your written permission.
If you believe your privacy rights have been violated, you can file a complaint with Fuller Living or with the United States Department of Health and Human Services at: Medical Privacy Complaint Division Office for Civil Rights U.S. Department of Health & Human Services 200 Independence Avenue, SW Room 509H, HHH Building Washington, DC 20201 1-800-368-1019 Filing a complaint will in no way affect the care or services you receive from Fuller Living.
We ask for information from you to determine what service or help you need, develop a service plan with you, and give you the medically necessary services. The information may also be used to determine your charges for services or collection of payments from insurance companies or other payment sources.
There is no law that says you must provide us with any information. However, if you choose to provide some information, it can limit our ability to serve you well. If you are seeking services because of a court order and refuse to provide information, that refusal may be communicated to the court.
Children and adolescents have the right to privacy and confidentiality. If you are under 18, you may request that information about you be kept from your parents. If you are a risk to yourself or others, or if there is reason to believe you are being abused or neglected, or have been abused and neglected in the past, confidentiality will be broken. Parents or appropriate government services will be notified. Parents should not attempt to use therapy to get information about their children from the therapist. Information a minor discloses during treatment should not be used in custody hearings. If you are at least 16, you may ask for mental health services without the consent of your parents, but you may have to pay for the services if you do not want your parents to know.
Please sign to indicate you have read and understood the information presented in this form.