Roots Informed Consents/ISP/VA - Staff Requested

Consent for Services, Financial Agreement & Assignment of Benefits

393 N Dunlap St. #300  St. Paul, MN 55104
P: 612.564.5933   F: 612.564.5932




Thank you for choosing Roots Recovery/Minnesota CarePartner. Our goal is to provide you with the best service possible so that you can receive hope and healing. We look forward to working with you to improve your life and your relationships.

For behavioral health services to be most effective, it is essential to have these services coordinated with other health care providers. Information will only be shared in accordance with the Privacy Policies of Roots Recovery/Minnesota CarePartner. For any person or institution that is not directly related to treatment, payment of services or health care operations of Roots Recovery/Minnesota CarePartner, all protected health information will be kept confidential UNLESS you sign a specific authorization. However, all health care providers are legally required to report and release the following information without specific authorization: Suspected physical/sexual abuse and/or neglect of a child or elderly person, to prevent injury to self or others, in a medical emergency to save lives, or if ordered by the court.

This document is an agreement between Roots Recovery/Minnesota CarePartner and the Patient and/or the Patient’s Guarantor (“You”). In consideration of the behavioral health care services provided to you or the Patient and on all other accounts for future care by Roots Recovery/Minnesota CarePartner, you agree as follows:

CONSENT FOR TREATMENT. You consent to health care as provided by Roots Recovery/Minnesota CarePartner as directed by the clinical team. You understand that due to factors beyond our control, such benefits and desired outcomes cannot be guaranteed. A variety of treatment methods will be used to provide relief of your symptoms and to improve your chances of recovery and increased health and wellness.

FINANCIAL AGREEMENT. You agree to pay your Roots Recovery/Minnesota CarePartner bill in full within 30 days of provided services. You will be charged our regular fees, or if you have health insurance or health benefits coverage, the rate Roots Recovery/Minnesota CarePartner has negotiated with that benefit provider. Acceptable forms of payment are cash, check, credit card (Visa, MasterCard, American Express or Discover), HSA or FSA debit cards. Should collection become necessary by legal suit or other means, you will pay all costs of collection including attorney fees, court costs, including charges and collection agency fees, which would be 35% of the balance signed, with or without suit.

INSURANCE SUBMISSION AND ASSIGNMENT OF BENEFITS. As a convenience to you, we can bill your insurance company for each service. You authorize Roots Recovery/Minnesota CarePartner to apply, on your behalf, to Medicare, Medicaid or any other insurance for payment of Roots Recovery/Minnesota CarePartner health care services. You confirm that the information you have provided to allow Roots Recovery/Minnesota CarePartner to apply for payment by any health care insurance or benefit is correct. Your authorized insurance, health plan, or statutory benefits, settlements and judgments to which you are entitled in connection with your Roots Recovery/Minnesota CarePartner health care services are to be paid directly to Roots Recovery/Minnesota CarePartner. In consideration of the health care services provided, you give Roots Recovery/Minnesota CarePartner an irrevocable assignment to all rights you have in your insurance, health plan, statutory benefits, settlements and judgments for which you are entitled, as necessary for payment for your Roots Recovery/Minnesota CarePartner health care service. You agree that you are financially responsible for charges that are not covered by this assignment and that you are responsible for satisfying any conditions necessary for insurance or health benefits.

CO-PAYMENT COLLECTION. Per your contract with your insurance company(s), all co-payments must be satisfied during each and every visit. There can be no exceptions due to legally binding contracts and uniform compliance rules.

INSURANCE PLAN RESTRICTIONS. You understand it is your responsibility to contact your insurance company regarding your plan benefits and exclusions. Exclusions may include, but not limited to, whether the Mental Health Provider you are scheduled to see is a provider for your plan, whether certain services are covered benefits, and if your plan requires a referral before seeing a specialist. Some plans have reduced benefits for restrictions, while others simply refuse to pay if you receive services outside of your contract. You are also responsible for all copayments, deductibles and charges not covered by your insurance as specified in your insurance plan contract.

SECONDARY INSURANCE. Having more than one insurer DOES NOT necessarily mean that your services are covered 100%. Secondary insurers have specific guidelines, stated in your contract with them, for what they will consider for payment in coordination with your primary insurance payment. We bill your primary and secondary insurance carrier as a courtesy. You are responsible for any balances after your insurance(s) has cleared. If the subsequent insurance carrier doesn’t pay after 45 days, we may turn the balance due to your responsibility. Subsequent insurance billing may be subject to a billing fee of $5.00 per claim.

MINOR PATIENTS. Clients under the age of 18 who have consented to their own health care as allowed by Minnesota. Stat. § 144.343, subd. 1 bear full financial responsibility for their own services, even if you elect to utilize health insurance coverage provided through your parents. Every attempt will be made to collect payment for services through insurance reimbursement prior to collecting from you.

RETURNED CHECKS AND CREDIT CARD DENIALS. If a check has been returned for insufficient funds or a credit card transaction is declined, Roots Recovery/Minnesota CarePartner will reverse the payment amount and add a $30.00 service fee to cover our costs.


 Attestation to Consent Agreements. 


Your Privacy Rights




Information about your rights under the Minnesota Government Data Practices Act

The Minnesota Government Data Practices Act (MN. Statutes, Chapter 13) seeks to protect your privacy as an individual when you provide us information that is necessary for the effective administration of service. The Act also facilitates the release of information which is public. Whenever we ask you to provide us with private or confidential information about yourself, we are required to tell you:

  • Why we need the information;
  • Whether you are required to give it to us;
  • What will happen if you give it or don't give it to us; and
  • Whom do we share the information with


1. Why

We need to obtain this information about you to provide the best possible services for your needs and interests. We may use the information for:

  • updating the county social service agency who contract with us;
  • assisting you in applying for and receiving benefits;
  • facilitating the survey of our program;
  • reporting wages and hours worked;
  • cooperating with licensing inspections;
  • monitoring your progress;
  • developing a program plan;
  • filling out reports required by law;
  • referring for treatment of medical/social/psychological problems.


2. Whether and What

The reasons we need the information make it important for you to give us the information requested. If you do not answer the questions we ask, it will be hard for us to provide you with the best possible services.


3. Who

The information you provide us will be shared with other people and agencies who work very closely with us to provide you services. We need to share information about you with them so that you can receive the best services. Some of the people who may see information about you are:

  • Social Service agencies who contract with our agency;
  • Social Security Office, if you apply and receive benefits;
  • US Dept. of Health and Human Services, to audit our program;
  • MN Dept. of Human Services, for licensing inspection;
  • MN Dept. of Economic Security, if you are referred for a job and receiving services from Division of Rehabilitation Services;


4. Questions

If you have any questions about the information we have about you, you may ask a staff person to tell you about it, to talk to your parent, guardian, or case manager.


You may also contact:

Data Privacy Office, MN  Dept. of Human Services, 4th Floor, Centennial Building, St. Paul, MN 55155. You may call 651-297-3173.

We ask that you sign this form. 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, or by mail.


 Privacy Rights Attestation: 


Initial Services Plan & Vulnerable Adult Determination





You can disregard this section if the ISP and/or VA were indicated "No" for inclusion.

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Signature Certificate
Document name: Roots Informed Consents/ISP/VA - Staff Requested
lock iconUnique Document ID: 421386fb2d13339cfcd0aa9a1fdb02b41b83dee2
Timestamp Audit
April 19, 2020 1:58 pm CDTRoots Informed Consents/ISP/VA - Staff Requested Uploaded by Justin Scharr - IP
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