10 North 1st Ave East Suite 202, Ely, MN 55731 218-216-8467
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.
For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client, to use or disclose the patient/client’s personal health information without the patient’s written authorization to carry out the health care provider’s own treatment, payment, or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This also can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard. Therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers, and referrals of a patient for health care from one health care provider to another.
Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request, or to obtain an order protecting the information requested.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
10 N 1st AVE E. Suite 202, Ely, MN 55731
PRACTICE POLICIES FOR YOUR INFORMATION
OPERATION OF BUSINESS:
MosaicSelf Counseling may disclose your information as necessary to facilitate the efficient operation of this business, including accountant and billing services, and may include consultation with other therapists who would assist to facilitate transfer of your care if anything should happen to me.
PERSONS INVOLVED IN YOUR CARE:
MosaicSelf may use or disclose health information to notify, or assist in the notification of (including identifying information or location) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your information, MosaicSelf will provide you with the opportunity to object to such use/or disclosures. In the event of your incapacity or emergency circumstances, MosaicSelf will disclose health information based on a need to know as well as in “good faith”, with your best interest in mind.
APPOINTMENTS, CANCELLATIONS, REMINDERS, BILLING
MosaicSelf must be notified at least 24 hours in advance (48 hrs is preferred to be available for others) if you need to cancel your appointment.
MosaicSelf uses an electronic record system, and a billing company has access to this to bill insurance payers for our session. The billing company (Resource Billing) will send you a bill for the fee not covered by insurance should you choose to use insurance. If you are having a difficulty paying your bill not covered by insurance, we will need to discuss it, and establish a payment plan, or the amount you owe will be referred to a collections agency. It is expected that you will pay co-pays at time of session. During Telehealth we will do together with a credit/debit card through IVY pay at the beginning of the session.
A $30.00 service charge will be charged for any checks returned for any reason for the special handling required.
I do require a credit card on file to bill for co-pays, no show or late cancellation fees. Currently, I use IVY pay which is a HIPAA compliant electronic method of payment. By signing this document, you agree to the use of your credit/debit card for copays, deductibles, no show or late cancellation fees.
*** YOU MUST PROVIDE YOUR INSURANCE CARD INFORMATION ***
(You will be billed as a self-pay client until such information is provided)
FEE SCHEDULE AND CONTRACT
Effective January 2023
Please note that this fee schedule is subject to change with a written notice
Initial Intake and Diagnosis Evaluation: $220.00
Individual Counseling:
38-53 min= $165.00
53min + = $180.00
Copy of Records - $35.00
Request for records may be made through your client portal by secure messaging through the client portal or email in writing.
NO SHOW fee for insurance based $50.00
Please call at least 24 hrs in advance (48 hours is preferred to be available for others) to cancel your appointment.
If you are private pay or out of network, you will be billed the session fee.
A discount is available for clients paying strictly with cash/check throughout on the same day as session. (Part of the above fees cover administrative time such as telephone calls to insurance companies and related paperwork.)
Court Appearances: $350.00/hr. portal to portal
You are fully responsible for all services rendered. Payment is expected through Resource Medical Billing. You will receive a bill directly from them. Please make checks payable to MosaicSelf Counseling. There will be a $30 charge for returned checks as non-sufficient funds or non-payable. Credit cards are accepted through IVY Pay.
Payment in full is expected. Please talk to me if you are having an exceptional hardship to discuss monthly payments as an alternative. If you become delinquent on a payment, your name, address, and telephone number will be given to a collection agency along with the amount owed plus 10% interest by Fairview Billing. By signing the last page you agree to waive your right to confidentiality in the instance of collection of fees owed whereby a collection agency needs to become involved due to your lack of payment.
Signature Authorization: This constitutes my authorization for MosaicSelf Counseling and its billing and programming associates, and any other associates that may be hired to file claims on my behalf or otherwise help in the operations of MosaicSelf Counseling (i.e. secretarial or billing personnel)
Assignment of Insurance: I hereby authorize payment of all insurance benefits for mental health to the holder of this authorization.
Authorization for Release of Medical Information and Waiver: For mental health services provided by MosaicSelf Counseling, I authorize any holder of medical information documentation about me to release to my insurance company and their agents and carriers any information needed to determine these benefits or benefits payable for this and/or a copy of this authorization to be used in place of the original and request payment of medical insurance benefits to the party who accepts assignment. By signing below you are waiving your right to confidentiality in regard to your insurance company. They have the right to review your file.
If for some reason I need to cancel our appointment I will either call, text or send an email-whichever you prefer. I have never had to cancel because of weather. If you are not able to make our meeting because of weather, please let me know as soon as you are able.
I do take time away to participate in trainings and vacations. This will be discussed in our sessions.
The standard meeting time for psychotherapy is 45-57 minutes. Requests to change the usual length session needs to be discussed with the therapist in order for time to be scheduled in advance, and may not be covered by insurance.
TELEPHONE ACCESSIBILITY
If you need to contact me between sessions, please leave a message on my voice mail at 218-216-8467. I am often not immediately available; however, I will attempt to return your call. Please note that face-to-face sessions are highly preferable to phone sessions. However, in the event that you are out of town, sick or need additional support, phone sessions may be available. If a true emergency situation arises, please call 911 or go to any local emergency room.
SOCIAL MEDIA AND TELECOMMUNICATION
Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.
ELECTRONIC COMMUNICATION
I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. I utilize the Spruce app on my cell phone which offers HIPAA compliant email and messaging. You will need to make an account on your device when I send you an invite. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of Minnesota. Under the Minnesota Telemedicine Parity Act of 2015, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that: (1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. (2) All existing confidentiality protections are equally applicable. (3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee. (4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent. (5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally the therapist.
MINORS
If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.
TERMINATION
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.
Should you fail to attend an appointment for two consecutive scheduled sessions, unless other arrangements have been made in advance, for legal and ethical reasons I must consider our professional relationship discontinued.
FINANCIALLY RESPONSIBLE AGREEMENT: I certify that I have read and understand the preceding and that the information I provided is true and correct. I agree to take full responsibility for the entire amount due for any and all services rendered by MosaicSelf Counseling
NOTE: MosaicSelf is NOT for clients with Criminal Court Issues, or Open Child Protection/Court Custody Cases.
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