Adult Mental Health Intake Packet - eSignature
393 N Dunlap St. #300 St. Paul, MN 55104
P: 612-289-5656 F: 651-925-0278
Client Date of Birth:
Person Signing this form is:
Name of Person Signing this Form:
As a Minnesota CarePartner client, you have a right to:
As a recipient of services from a Licensed Marriage and Family Therapist, you have a right:
As a recipient of services from a licensee of the Minnesota Board of Behavioral Health and Therapy, you have a right to:
Attestation to Contents of and Orientation to Bill of Rights
I have read and understand the Mental Health Bill of Rights
Client Date of Birth:
Person Signing this form is: Client Parent/Guardian
Name of Person Signing this Form:
THIS NOTICE DESCRIBES HOW PRIVATE INFORMATION, INCLUDING HEALTH INFORMATION, ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Your health record contains personal information about you and your health. This information, which may identify you and relates to your past, present, or future mental and/or physical health is referred to as Protected Health Information (PHI). “Protected information” is individually identifiable information. We are committed to protecting the privacy of your health information by complying with applicable federal and state privacy and confidentiality laws. You have privacy rights under the Minnesota Government Data Practices Act, the federal Health Insurance Portability and Accountability Act (HIPAA), and other state and federal laws, rules, and regulations. These laws protect your privacy but also allow us to give information about you to others if the law requires or permits it. We are required by law to abide by the terms of this Notice of Privacy Practice and to provide you with this notice. We reserve the right to change the terms of this notice and apply any changes to all present and future information that we collect about you.
This Notice of Privacy Practices describes how we may use or disclose your protected information, with whom that information may be shared, and the safeguards we have in place to protect it. It also describes your rights regarding how you may gain access to and amend your protected information. You have the right to approve or refuse the release of specific information except when the release is required or authorized by law or regulation.
WHY DO WE ASK FOR PRIVATE INFORMATION?
We provide a number of mental health and other services. We may ask you for information so we can:
HOW WE MAY USE OR DISCLOSE YOUR PROTECTED INFORMATION
Following are examples of permitted uses and disclosures of your protected information. These examples are not exhaustive. We may tell you before we release your information but are not required to in these instances.
Required Uses and Disclosures
By law, we must disclose your information to you unless it has been determined by a competent medical authority that it would be harmful to you. We must also disclose information to the Minnesota Department of Health and Human Services and the Secretary of the Department of Health and Human Services (DHHS) for investigations or determinations of our compliance with laws on the protection of your information.
Treatment is when we provide, coordinate, or manage your health care and other services related to your care. This includes the coordination or management of your care with an allowed third party. An example of treatment would be when we consult with another health care provider, such as your family physician. In emergencies, we will use and disclose your protected information to provide the treatment you require.
Payment is when we obtain reimbursement from insurance companies or other agencies/counties for your services. Your protected information will be used, as needed, to obtain payment for your services. This may include certain activities the County might undertake before it approves or pays for the services recommended for you such as determining eligibility or coverage for benefits.
Health Care/ Human Services Operations
Operations are activities that relate to the performance and operation of our practice. Examples are quality assessment and improvement activities, program eligibility determination, and care coordination, along with business-related matters such as audits and administrative services, licensing inspections and government regulation requirements, investigations, and financial management of the organization. We may use or disclose, as needed, your protected information to support the daily activities related to health and human services care. We share your protected information with third-party "business associates" who perform various activities (for example; billing, referral sources). The business associates are also required to protect your information.
Required by Law
We may use or disclose your protected information if law or regulation requires the use or disclosure.
We may disclose protected information during any judicial or administrative proceeding in response to a court order or subpoena.
We may disclose your protected information to researchers/evaluators when authorized by law.
EXCEPTIONS TO PRIVACY AND CONFIDENTIALITY
In general, the law protects the privacy of communication between a client and a therapist. We only can release information about your treatment to others if you sign a release of information form. You can revoke any such authorization at any time in writing. However, in the following situations your authorization is not required for us to release information:
Please discuss any questions or concerns you have about confidentiality with your provider at any time. If you have specific legal questions about the law regarding confidentiality, the exceptions, and how it may relate to your situation, please seek formal legal advice from an attorney.
YOUR RIGHTS REGARDING PROTECTED INFORMATION
Right to Inspect and Copy
You may inspect and obtain a copy of your protected information for as long as we are required to maintain it.
This right does not include inspection and copying of the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected information that is subject to law that prohibits access to protected information.
Right to Request Restrictions
You may ask us not to use or disclose any part of your protected health information for treatment, payment, or health care operations. In your written request, you must tell us:
If we cannot reasonably accommodate the request, we are not required to agree. If the restriction is mutually agreed upon, we will not use or disclose your protected health information in violation of that restriction, unless it is needed to provide emergency treatment. You may revoke a previously agreed upon restriction, at any time, in writing.
Right to Request Alternate Communications
You may request that we communicate with you using alternative means or at an alternative location. We will accommodate reasonable requests, when possible.
Right to Request Amendment
If you believe that the information we have about you is incorrect or incomplete, you may request an amendment to your protected information as long as we maintain this information. While we will accept requests for amendment, we are not required to agree to the amendment.
Right to An Accounting of Disclosures
You may request that we provide you with an accounting of the disclosures we have made of your protected health information. This right applies to disclosures made for purposes other than services, treatment, payment or operations as described in this Notice of Privacy Practices. The disclosure must have been made after April 14, 2003, and no more than 6 years prior to the date of request. This right excludes disclosures made to you or others you authorized to receive information regarding your care.
FURTHER QUESTIONS OR COMPLAINTS
If you have any questions about the information we have about you, you may ask a staff person to tell you about it, or talk with your parent, guardian, or case manager.
You can contact Minnesota Care Partner’s Privacy Officer Katy Armendariz, CEO, 612.289.5656
You may also contact: Data Privacy Office, MN Dept. of Human Services, 4th Floor, Centennial Building, St. Paul, MN 55155. Phone # 651-297-3173.
ACKNOWLEDGMENT OF RECEIPT OF THIS NOTICE
We ask that you sign this form. Our intent is to make you aware of the possible uses and disclosures of your protected information and your privacy rights. If you decline to provide a signed acknowledgment, we will continue to provide you services, and will use and disclose your protected information for treatment, payment, and operations as disclosed in this notice.
Your signature is proof that you have received this form and understand what it says. If you have a guardian, they will be asked to sign for you. This notice about collecting and sharing information about you applies to all contacts we have with you when you are in our program, whether these contacts are in person, on the phone, electronic, or by mail.
Attestation to Review and Understanding of Privacy Rights I have received and reviewed the privacy rights. The privacy rights have been explained to me.
Client or Parent/Legal Guardian: Date:
Name of Person Signing this Form:
A. PERMISSION FOR TREATMENT
I agree to permit employees and interns of Minnesota CarePartner (MNCP) to provide services to me. I understand that Minnesota CarePartner can make no guarantees about the outcome of my treatment, but that I can expect to receive services that are ethical and professional. I understand that Minnesota CarePartner agrees to comply with all privacy laws and respects my right to confidentiality. As a client, I agree to attempt to be honest and to disclose information to assist the MNCP staff in providing appropriate services.
B. HEALTH CARE SERVICES FINANCIAL AGREEMENT
C. ELECTRONIC COMMUNICATION
EMAIL COMMUNICATION I understand that e-mail is not a secure means of communication. I am aware that the provider may decline to communicate via e-mail based upon the nature of medical information. By providing my email address, I give permission to use electronic mail as a means of communication regarding my care. I understand that I may withdraw this authorization at any time by notifying Minnesota CarePartner staff or my provider in writing.
TEXT MESSAGING I understand that text messaging is not a secure means of communication. I am aware that the provider may decline to communicate via text messaging based upon the nature of medical information. I give permission for MNCP to use text messaging as a means of communication regarding appointment reminders, scheduling and reminders regarding paperwork. I understand that I may withdraw this authorization at any time by notifying Minnesota CarePartner staff or my provider in writing.
SOCIAL MEDIA:I understand that it is the policy of Minnesota CarePartner that providers will not interact with clients on any social media platform to protect my privacy.
D. Appointment Cancellation Policy Agreement
Under the above conditions, I provide my consent to receive services from Minnesota CarePartner
393 N. Dunlap St.
St. Paul, MN 55104
P: 612-289-5656 F: 651-925-0278
Minnesota CarePartner/Roots Recovery allows, under certain conditions, the use of Telemedicine technology for Therapy and Skills sessions at the provider’s discretion and with the patient/client's consent. Telemedicine is not intended to be a complete replacement for face-to-face sessions and face-to-face sessions are expected to remain the primary mode of service.
Acceptable Reasons for the use of telemedical include such things as: Severe weather or transportation barriers making it difficult to travel to your clinician’s office, having to remain in home due to ill child, public health crisis, having your ride cancel at the last minute, scheduling conflicts or being out of town.
Keep in mind, however, that there might be certain clinical, ethical, or legal factors that would preclude or limit the use of Telemedicine. Your provider will discuss these factors with you on a case-by-case basis.
If you agree to participate in some sessions through telemedicine, please be reassured that all the standard issues related to privacy and confidentiality will still apply. However, please be advised that telemedicine uses the internet, which is not as secure as the privacy of your provider’s office and certain service providers might store copies of videos. It is possible that communication might be intercepted (hacked) or otherwise compromised. Additionally, telemedicine being a relatively new format, the empirical evidence for its efficacy, while promising, is limited.
Also, be aware that if you elect to not use telemedicine for therapy, this will not affect your ability to continue scheduling face-to-face sessions with your provider as available. Please ask your provider how telemedicine sessions factors into the no show, and late cancelation policy.
I agree to engage in sessions through telemedicine. I am aware of the potential limitations to privacy, confidentiality, and service connections associated with telemedicine.
I agree that I will take responsibility to ensure that I am in a place that allows sufficient privacy when engaging in telemedicine and that I will take every precaution to ensure that my confidential health information is protected on my end of the telemedicine connection.
I attest that I have reviewed and understand the forms in this document, as listed below:
I agree to the information contained in each form to which I have attached my initial, attestation, or signature.
Client Legal Name: Preferred Name:
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Parent/Legal Guardian Name (If under 18):
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If you have questions about the contents of this document, you can email the document owner.
Document Name: Adult Mental Health Intake Packet - eSignature
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