1821 University Avenue W. Ste S303
Client Information Forms
Take Flight Counseling Services, LLC.
1821 University Avenue Suite#S303
Saint Paul, MN 55104
CONSENT, CLIENT’S RIGHTS, POLICIES, HIPAA INFORMATION
This form references the clinical relationship between:
AS A CLIENT, YOU HAVE THE RIGHTS TO:
1. Health Care that meets professional standards.
2. Courteous and individualized health care that is fair and given without discrimination as to race, color, creed, gender, sexual orientation, national origin, source of payment, ethical and political beliefs.
3. Informed participation in all decisions concerning your health care.
4. Information about the qualifications, names, titles or personnel responsible for providing your health care.
5. Privacy during any interview, testing, and treatment.
6. Right to refuse any treatment, medications, or participation in research experiments.
7. Coordination and continuity of health care, including consultation regarding your case with other professionals.
8. Appropriate instruction or education from staff about your problem.
9. Access to all health records pertaining to you.
10. Information on the fees for services provided by Private Practice/Therapist listed above.
11. Information about diagnosis, prognosis and treatment, including benefits, alternatives, and the risks involved. Including, but not limited to the acknowledgement that psychotherapy may entail emotional pain, stress, and life changes. Although, psychotherapy helps many people, it may not always be helpful or effective.
12. Confidentiality of all records (except as otherwise provided by law or third party payer contracts) and all communications, written or oral, between patients, and health care providers.
If you fail to cancel a scheduled appointment, we cannot use this time for another client. You may be billed a full session fee if: 1) You do not show up 2) Cancel with less than a 12 hour notice 3) or don’t make alternate arrangements with the therapist. Illness or emergencies are excluded. If there are more than 4 missed appointments, the therapist has a right to terminate the therapeutic relationship and refer you to another professional if requested by the client
RELEASE/EXCHANGE/ASSIGNMENT OF BENEFITS
I consent to the release of information from the therapist to my insurance company, EAP, third party payer, and/or managed care group or therapist billing service to submit claims on my behalf and/or facilitate payment and continued coverage under the mental health benefit of my policy.
I consent to properly authorize information being transmitted via cell phone (including voice messages), fax, and/or email with the understanding that complete confidentiality cannot always be guaranteed.
I understand that my signature indicates that I am ultimately responsible for payment and services rendered. I also understand that if my account comes past due, a collection agency will be contacted.
HIPAA – NOTICE OF PRIVACY, PRACTICES, RIGHTS TO ACCESS & PROTECT YOUR HEALTH RECORDS CONFIDENTIALITY NOTICE
The information you share during psychotherapy sessions is protected by State and Federal laws of confidentiality. Your clinician is strictly prohibited from re-disclosing or sharing your private health information without your express written authorization. Anyone seeking information about you or what you disclosed during a counseling session will be told that Take Flight Counseling Services can neither confirm nor deny that you are a client of our agency without a proper authorization of release.
You have the following rights related to your health record under the law including: 1) a health care provider, or person who gets health records from a provider, must have your signed and dated consent to release your health record, except for specific reasons in the law. 2) You see your health record for information about any diagnosis, treatment, and prognosis. 3) You can ask in writing, for a copy or summary of your health care record, which must be given to you in a timely manner, unless it would be detrimental to your physical or mental health, or cause harm to another. 4) 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 MN law for copying your record.
RELEASE OF YOUR HEALTH RECORDS WITHOUT YOUR CONSENT
There are specific times the law allows health record information held by your provider to be released without your consent. Some of the reasons for release under federal law are: 1) for specific public health activities 2) when health information about victims of abuse, neglect, to domestic violence must be released to a government authority 3) for health oversight activities 4) for specific law enforcement purposes 5) for certain organ donation purposes 6) for judicial and administrative proceedings 7) When health information about decedents is required for specific
board 9) to stop a serious threat to health or safety 10) for specialized government functions related to national security.
LIMITS OF CONFIDENTIALITY FOR MINORS
All minors are subject to the same limits of confidentiality listed above. In addition, minor clients need to be aware that if they are not emancipated, their custodial parents or guardians have legal rights to information about their child’s condition, diagnosis, progress, and medical records. However, a minor child does have a right to complete confidentiality in obtaining information about venereal diseases, pregnancy, associated conditions, and alcohol or other drug use.
UNDER MINNESOTA LAW THE FOLLOWING AGENCIES MAY HAVE ACCESS TO YOUR HEALTH RECORDS, which are: 1) the departments of Health, Human Services, Public Safety, Commerce, Employee Relations, Labor & Industry, and Education. 2) Insurers and employers in workers compensation cases 3) Ombudsman for Mental Health and Mental Retardation 4) Health Professionals licensing boards/agencies 5) victims of serious threats of physical violence 6) the State Fire Marshall 7) local welfare agencies 8) medical examiners or coroners 9) school, childcare facilities, and Community Action Agencies to transfer immunization records 10) Parent/legal guardian who did not consent for a minor’s treatment, when failure to release health information could cause serious health problems 11) law enforcement agencies 12) insurance companies and other payers paying for an independent medical examination.
I have read and agree to the “Consent, Client’s Rights, Policies, HIPAA, and Therapeutic Issues” form by the therapist listed above who is providing treatment.
FEDERAL GUIDELINES ON CONFIDENTIALITY:
Please indicate below whether you would like a copy of the Federal guidelines on confidentiality: Health Insurance Portability & Accountability Act (HIPAA). If yes, please inform clinician that you would like a copy.
________ YES _________ NO
Your signature below indicates that you have read and understand the limits of confidentiality as explained above.
Print Name Date
Signature of Parent or Guardian (if applicable)