Fuller Living Informed Consent

Please correct the errors described below.

1. I understand that my mental health provider can provide teletherapy services when in a situation where I can not physically be at my providers office. 2. My mental health provider has explained to me how the video conferencing technology will be used to affect such a session will not be the same as a direct client/provider visit due to the fact that I will not be in the same room as my provider. 3. I understand there are potential risks to this technology, including interruptions and technical difficulties. 4. I understand that my informed consent for therapy services that I signed in order to initiate services is also applicable to me when using teletherapy. 5. I understand that my provider will use a Hipaa compliant web platform to provide services (doxy) and then another platform if doxy doesn't work and that I will receive a link to the “online meeting room”. 6. I understand that my provider will be providing teletherapy from a distant site and will ensure that my privacy is protected. 7. I understand that nobody else will be in the room with my provider while meeting with me. 8. I understand that my provider has no control over who is with me or in the same room as me at my location during the time of service. 9. I understand that sessions are still billed as either 30 minutes, 45 minutes, or 55-60 minutes depending on what is applicable and that telemedicine sessions are billed to the insurance company. 10. I have had a direct conversation with my mental health provider during which I had the opportunity to ask questions in regard to the teletherapy session. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand. 11. I understand that although my provider is willing to provide teletherapy, if my insurance doesn't cover it I understand that I'm responsible for what my insurance doesn't cover. It is our understanding, at this time, that most insurances are covering this service. By signing this form, I certify: That I have read or had this form read and/or had this form explained to me That I fully understand its contents including the risks and benefits of teletherapy. 11. That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction. If I'm a danger to myself or others, you have my permission to contact the following person and disclose to them that I am a danger to myself or others and what my plan is to harm myself I also agree that if I'm a danger to myself or others I will stay at the location that I'm at.(please identify the following person):

PLEASE NOTE: We have several providers who work under the license of a supervisor. Please ask us about this if it is a concern for you. When a provider works under a supervisor, their work is being reviewed and signed off by a licensed provider.These providers are not credentialied BY OPTUM/UBH, HOWEVER, THEIR SUPERVISOR IS AND YOU ARE CONSENTING TO THE UNLICENSED PROVIDER NOT BEING CREDENTIALED. Fees: $200 per 55 minute Session $240 Initial Diagnostic Session(s) or amount told otherwise Cancellation Policy: We have a 24 business hour cancellation policy. We hold times in our schedules just for you. If you need to cancel for any reason with less than 24 business hours there will be a charge of $50. We will gladly waive the fee if the opening created by your cancellation is filled. We will routinely charge your credit card for unpaid co-pays and insurance. We send statements only on request. YOUR RIGHTS: 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 right: -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 board of Licensing Board or Boards which contain the credentials of a therapist; -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 on the basis of 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; and -To be free from exploitation for the benefit or advantage of a therapist. -To refuse treatment at any time. 1. Our therapists use a blend of relevant therapies and biblically based Christ-centered counseling. If faith is not applicable then faith is NOT incoporated into treatment. 2. Confidentiality: Information that a client shares with a therapist is completely confidential, except where otherwise specified by law. Information pertaining to a client’s record, or a client’s identity, cannot be released to any individual or agency outside of Fuller Living & Associates, LLC without the written consent of the client. For the purposes of gaining greater perspective, case scenarios may be shared within Fuller Living & Associates, LLC. I understand that Fuller Living & Associates will use email to communicate between offices and clients and that this entails some risk. 3. 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 is required to 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. 4. We reserve the right to use a collection agency to collect overdue payments. 5. I/we authorize payment of benefits to Fuller Living & Associates, LLC for services rendered to myself and/or dependents. 6. I/we hereby authorize the release of required information to my insurance company. 7. Benefits quoted from insurance companies are not a guarantee of payment. You agree to be responsible for the costs of services if they are not reimbursed by your insurance company. JeNee Olson, Uyanga Bayandalai, and Amber Fuller are contractors of the group and their education and experience is appropriate. A copy of Fuller Living & Associates, LLC Privacy Disclosure Statement is available to you and has been offered to you. I have read and understand the information presented in this form.

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 get access to 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 it's 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 with respect to PHI. The terms we, our, and us refer to (Fuller Living) and the terms you and your refer to the client. Fuller Living & Associates, LLC provides counseling services within the context of the Christian faith for those who desire Christian counseling. Those who wish to not implement faith into their counseling session have this right and should inform therapist of their spiritual beliefs and counseling desires within this context. Notice Information This Notice of Privacy Practices describes how we may use and disclose your PHI to carry out treatment, payment, and health care operations and for other purposes that are specified by law. We reserve the right to change this notice. The changes will apply for PHI we already have about you and PHI we receive about you in the future. We will provide an updated Notice to you 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 is provided by you, 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 amount of PHI necessary. Whenever possible, we will deidentify: you or encrypt your personal information 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 with respect to your PHI. Obtain a copy of this Notice. 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. Request restrictions. 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 we are not required to agree to any restrictions. Inspect and copy. You have the right to inspect and get a copy of your PHI for 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 supplies that are necessary 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. Request amendment. If you feel that your PHI is incomplete or incorrect, you may ask us to amend it. You may ask for an amendment for 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 or disagreement with our decision. Receive a list (an accounting) of disclosures. You have the right to receive a list of the disclosures (an accounting) that we have made on your PHI. The list will not include disclosures that we are not required to track, such as disclosures for the purposes of treatment, payment, or health care operations; disclosures which you have authorized us to make; disclosures made directly to you or to 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 state the time period for which you would like us to list the disclosures. We will not include disclosures made more than seven years prior to the date of your request. You will not be charged for the first disclosure list that you request, but you may be charged for additional lists provided with the same l2-month period as the first. Request confidential communication. You may ask us to communicate with you using alternative means or alternative 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 made in writing and 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 we are not required to agree to any restrictions. Special Rules for Psychotherapy Notes. Only psychotherapy notes collected by a psychotherapist 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. To provide, coordinate, or manage health care and related services for you to make sure you are receiving appropriate and effective care. For example, we may contact you to provide appointment reminders, information about treatment alternatives, or to refer you to other health-related benefits and services that may be of interest to you. Or we might contact another health care provider or third party to share information to consult with them about the services we are providing to you. Payment. To obtain payment or reimbursement for services provided to you. For example, we may need to disclose PHI to determine eligibility for treatment or claims payment. Health Care Operations. 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. Business Associates. Our business associates perform some health care 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. Health Plan Sponsor. We may disclose PHI to a group health plan administrator, which may, in turn, disclose such PHI to the group health plan sponsor, solely for purposes of administering benefits provided by Fuller Living. Individuals involved in your care or payment for your care. 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 in payment related to your care. As required by law. We must disclose PHI about you when required to do so by law. Less common reasons for our use and disclosure of 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 threat to public health and safety. We may disclose PHI to avoid a serious and imminent threat to your health or safety or to the health or safety of others. Military or national security and intelligence activities. 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. To provide reminders and benefits information to you. 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 who have other health insurance or eligibility for government benefit programs. Worker's compensation. We may disclose PHI to comply with worker's compensation laws and other similarly legally established programs. Food and Drug Administration (FDA). We may disclose PHI to a person or company required by the FDA to report adverse events or product defects or problems, track products, enable product recalls, make repairs 01' replacements, monitor post-marketing as required. Public Health. We may disclose PHI to a public health authority that is permitted by law to receive the information for public health activities. This disclosure might be necessary to prevent or control disease, injury, or disability. Abuse or neglect. We may make disclosures to government authorities or social service agencies as required by law in the reporting of abuse (financial, emotional, physical,sexual, and/or verbal), 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 compliant investigation or compliance review. Correctional facility. We may use or disclose PHI, as authorized by law, if you are an inmate of a correctional facility. Law enforcement. We may disclose PHI to law enforcement officials for the purpose of identifying or locating a suspect, witness, or mission person, or to provide information about victims or crimes. Your written permission 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. You may withdraw your permission If you do provide your written authorization and then later want 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. You may file a complaint 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. Data Privacy Why do we ask for information? We ask for information from you to determine what service or help you need, develop a service plan with you, and give you the services that are medically necessary for you. The information may also be used to determine your charges for services or for collection of payment from insurance companies or other payment sources. Do you have to give information to us? There is no law that says you must give us any information. However, if you choose to not give us some information, it can limit our ability to serve you well. What will happen if you do not answer the questions we ask? If you are here because of a court order, and you refuse to provide information, that refusal may be communicated to the court. Without certain information, we may not be able to tell who should pay for your services. What privacy rights do minors have? If you are under 18, you may request that information about you be kept from your parents. You must give us your request in writing, describe the information, and tell us why you don't want your parents to see it. If, after reviewing your request, Fuller Living staff believes that giving information to your parents is not in your best interest, we will not share the information. If Fuller Living staff believes this information could be safely shared with your parents, we will inform you of that decision. 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.

Your information will be encrypted.