Services & Financial Agreement - eSignature


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Minnesota CarePartner Services Agreement

 

Client Name:  

 Client Date of Birth:

Person Signing this form is:

 

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. 

  1. I agree to attend scheduled appointments or notify service providers if I need to reschedule an appointment. 
  2. I agree to participate in required treatment planning. 
  3. I understand that my diagnostic assessment and/or treatment may be being completed by a Licensed Mental Health professional, a Graduate level Clinical Intern Therapist, or a Master’s level Mental Health Practitioner who is being clinically supervised by a Licensed Mental Health professional.

B. HEALTH CARE SERVICES FINANCIAL AGREEMENT

  1. I authorize Minnesota CarePartner to correspond with my insurance company as I have indicated, and with any insurance company with which I will be covered in the future to which I will ask Minnesota CarePartner to submit claims. I understand that it is my responsibility to know the benefits and limits of my insurance. I request payment of authorized insurance benefits be made to Minnesota CarePartner for any services furnished to me by any provider employed or contracted by this agency.  I authorize Minnesota CarePartner to release to Minnesota Health Care Programs, its agents, or any insurance company, any information needed to process claims, determine benefits or the benefits payable for related services. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize Minnesota CarePartner to release all information necessary to secure the payment.
  2. Insurance claims will be handled as follows:
    1. I do not want Minnesota CarePartner to file claims to my insurance company and I will pay fees in full upon receipt of an invoice for services.
    2. I do not have insurance to cover services performed by Minnesota CarePartner and will pay fees in full upon receipt of an invoice for services or prior to services as required.
    3. Minnesota CarePartner will file claims to the insurance I have indicated and I will pay any balance not paid by insurance. If my insurance is discontinued I will pay fees in full upon receipt of invoice for services.
  3. If my insurance company sends me payment for services performed by Minnesota CarePartner and I have not yet paid my balance in full, I will make payment of at least the amount received from insurance within five working days.
  4. This form also authorizes the release of any medical information necessary to process this claim.  I understand that I am financially responsible for health care charges not covered by this authorization.  
  5. I hereby request and authorize direct payment of benefits specified under my policy or any policy paying benefits to: Minnesota CarePartner 

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 

  1.  Minnesota CarePartner is committed to providing all of our patients with exceptional care. When a service recipient cancels without giving enough notice, they prevent another patient from being seen. 
  2. Please call your Provider on the day prior to your scheduled appointment to notify them of any changes or cancellations. If arriving late to a scheduled appointment, your late arrival will require that the session end at the scheduled time, meaning your session will unfortunately be shorter. 
  3. If prior notification is not given, you will be given three opportunities (due to no call/no show/ late cancellation) before your Provider decides on the continuation of services.

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Signature Certificate
Document name: Services & Financial Agreement - eSignature
lock iconUnique Document ID: 1d60f83fba670904574efcc173ba7d3013128589
Timestamp Audit
August 30, 2021 1:03 pm CSTServices & Financial Agreement - eSignature Uploaded by Roots Recovery - rootsforms@mncarepartner.com IP 206.84.184.37