PRACTICE PRIVACY NOTICES AND POLICIES
Kind Mind Counseling Center 2604 1st Ave Hibbing, MN 55746 (218)263-5949
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. KIND MIND COUNSELING CENTER PLEDGE REGARDING HEALTH INFORMATION:
Kind Mind Counseling Center understands that health information about you and your health care is personal. Kind Mind Counseling Center is committed to protecting health information about you. Kind Mind Counseling Center does create a record of the care and services you receive from me. This record is 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 Kind Mind Counseling Center may use and disclose health information about you. Kind Mind Counseling Center also describe your rights to the health information Kind Mind Counseling Center does keep about you, and describe certain obligations regarding the use and disclosure of your health information. Kind Mind Counseling Center is required by law to:
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways Kind Mind Counseling Center use and disclose health information. For each category of uses or disclosures Kind Mind Counseling Center will explain what is meant and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways Kind Mind Counseling Center is 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. Kind Mind Counseling Center 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, Kind Mind Counseling Center may disclose health information in response to a court administrative order. Kind Mind Counseling Center 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, Kind Mind Counseling Center 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:
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on January 1, 2022
Acknowledgement of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.
PRACTICE PRIVACY NOTICES AND POLICIES
Kind Mind Counseling Center Practice Policies2604 1st Ave. Hibbing, MN 55746
PRACTICE POLICIES FOR YOUR INFORMATION
OPERATION OF BUSINESS:
Kind Mind Counseling Center 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:
Kind Mind Counseling Center 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, Kind Mind Counseling Center will provide you with the opportunity to object to such use/or disclosures. In the event of your incapacity or emergency circumstances, Kind Mind Counseling Center 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
LATE Cancellations & NO SHOWS will be subject to a $100.00 fee if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE, 48 hours is preferred to be available for others. This is necessary because these sessions are time commitment made to you and is held exclusively for you.
If you are late for a session, you may lose some of that session time. If you are private pay or out-of-network you will be billed the full session fee.
Kind Mind Counseling Center uses an electronic record system, and a billing company has access to this to bill insurance payors for our session. The billing company (currently Fairview Healthline 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 you are responsible to make the copay payment here.
A $30.00 service charge will be charged for any checks returned for any reason for the special handling required.
Kind Mind Counseling Center does require a credit card on file to bill for co-pays, no show or late cancellation fees. Currently, Kind Mind uses Fairview Billing company online payment link, 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 October 2021
Please note that this fee schedule is subject to change with a written notice
Initial Intake and Diagnosis Evaluation: $275/hr
Individual Counseling:
38-53 min= $200.00
53min + = $250.00
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.
NOTE: NO SHOW fee $100
Please call at least 24hrs 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 Fairview Healthline Billing. You will receive a bill directly from them. Please make checks payable to Kind Mind Counseling Center. There will be a $30 charge for returned checks as non-sufficient funds or non-payable. Credit cards are accepted through Fairview Healthline Billing.
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 Kind Mind Counseling Center 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 Kind Mind Counseling Center (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 Kind Mind Counseling Center, 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 your therapist does need to cancel our appointment, they will either call, text or send an email-whichever you prefer.
Kind Mind therapists do take time away to participate in trainings and vacations. This will be discussed in your sessions.
The standard meeting time for psychotherapy is 45-52 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 218-263-5949. Kind Mind Center therapists are often not immediately available; however, they will attempt to return your call within 48 hours. 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, your therapist does not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). Kind Mind therapists 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
Your therapist 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, do talk with your therapist about this. Your therapist may utilize the Spruce app on a cell phone which offers HIPAA compliant email and messaging. You will need to make an account on your device should you choose this option. While your therapist may try to return messages in a timely manner, Kind Mind Center 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. Your therapist 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. Your therapist may terminate treatment after appropriate discussion with you and a termination process if your therapist determines that the psychotherapy is not being effectively used or if you are in default on payment. Your therapist 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, your therapist 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 your therapist 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 Kind Mind Counseling Center.
Kind Mind Counseling Center 2604 1st Ave Hibbing, MN 55746 (218)263-5949
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. KIND MIND COUNSELING CENTER PLEDGE REGARDING HEALTH INFORMATION:
Kind Mind Counseling Center understands that health information about you and your health care is personal. Kind Mind Counseling Center is committed to protecting health information about you. Kind Mind Counseling Center does create a record of the care and services you receive from me. This record is 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 Kind Mind Counseling Center may use and disclose health information about you. Kind Mind Counseling Center also describe your rights to the health information Kind Mind Counseling Center does keep about you, and describe certain obligations regarding the use and disclosure of your health information. Kind Mind Counseling Center is required by law to:
- Make sure that protected health information (“PHI”) that identifies you is kept private.
- Give you this notice of my legal duties and privacy practices with respect to health information.
- Follow the terms of the notice that is currently in effect.
- Kind Mind Counseling Center can change the terms of this Notice, and such changes will apply to all information on file about you. The new Notice will be available upon request, in my office, and on my website.
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways Kind Mind Counseling Center use and disclose health information. For each category of uses or disclosures Kind Mind Counseling Center will explain what is meant and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways Kind Mind Counseling Center is 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. Kind Mind Counseling Center 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, Kind Mind Counseling Center may disclose health information in response to a court administrative order. Kind Mind Counseling Center 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:
- Psychotherapy Notes. your therapist does keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is: a. For my use in treating you. b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy. However, the practitioners have the same obligations to keep your information private.. c. For my use in defending myself in legal proceedings instituted by you. d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA. e. Required by law and the use or disclosure is limited to the requirements of such law. f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes. g. Required by a coroner who is performing duties authorized by law. h. Required to help avert a serious threat to the health and safety of others.
- Marketing Purposes. As a psychotherapist, Kind Mind Counseling Center will not use or disclose your PHI for marketing purposes.
- Sale of PHI. Kind Mind Counseling Center will not sell your PHI in the regular course of my business.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, Kind Mind Counseling Center can use and disclose your PHI without your Authorization for the following reasons:
- When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
- For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
- For health oversight activities, including audits and investigations.
- For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
- For law enforcement purposes, including reporting crimes occurring on my premises.
- To coroners or medical examiners, when such individuals are performing duties authorized by law.
- Specialized government functions, including ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or helping to ensure the safety of those working within or housed in correctional institutions.
- For workers' compensation purposes. Although my preference is to obtain an Authorization from you, Kind Mind Counseling Center may provide your PHI in order to comply with workers' compensation laws.
- Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. Kind Mind Counseling Center may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
- Disclosures to family, friends, or others. Kind Mind Counseling Center may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
- The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. Kind Mind Counseling Center is not required to agree to your request, and Kind Mind Counseling Center may say “no” if your therapist does believe it would affect your health care.
- The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
- The Right to Choose How Kind Mind Counseling Center Sends the PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and Kind Mind Counseling Center will agree to all reasonable requests.
- The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and Kind Mind Counseling Center may charge a reasonable, cost based fee for doing so.
- The Right to Get a List of the Disclosures Kind Mind Counseling Center Have Made. You have the right to request a list of instances in which Kind Mind Counseling Center have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. Kind Mind Counseling Center will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list Kind Mind Counseling Center will give you will include disclosures made in the last six years unless you request a shorter time. Kind Mind Counseling Center will provide the list to you at no charge, but if you make more than one request in the same year, Kind Mind Counseling Center will charge you a reasonable cost based fee for each additional request.
- The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. Kind Mind Counseling Center may say “no” to your request, but Kind Mind Counseling Center will tell you why in writing within 60 days of receiving your request.
- The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on January 1, 2022
Acknowledgement of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.
PRACTICE PRIVACY NOTICES AND POLICIES
Kind Mind Counseling Center Practice Policies2604 1st Ave. Hibbing, MN 55746
PRACTICE POLICIES FOR YOUR INFORMATION
OPERATION OF BUSINESS:
Kind Mind Counseling Center 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:
Kind Mind Counseling Center 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, Kind Mind Counseling Center will provide you with the opportunity to object to such use/or disclosures. In the event of your incapacity or emergency circumstances, Kind Mind Counseling Center 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
LATE Cancellations & NO SHOWS will be subject to a $100.00 fee if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE, 48 hours is preferred to be available for others. This is necessary because these sessions are time commitment made to you and is held exclusively for you.
If you are late for a session, you may lose some of that session time. If you are private pay or out-of-network you will be billed the full session fee.
Kind Mind Counseling Center uses an electronic record system, and a billing company has access to this to bill insurance payors for our session. The billing company (currently Fairview Healthline 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 you are responsible to make the copay payment here.
A $30.00 service charge will be charged for any checks returned for any reason for the special handling required.
Kind Mind Counseling Center does require a credit card on file to bill for co-pays, no show or late cancellation fees. Currently, Kind Mind uses Fairview Billing company online payment link, 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 October 2021
Please note that this fee schedule is subject to change with a written notice
Initial Intake and Diagnosis Evaluation: $275/hr
Individual Counseling:
38-53 min= $200.00
53min + = $250.00
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.
NOTE: NO SHOW fee $100
Please call at least 24hrs 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 Fairview Healthline Billing. You will receive a bill directly from them. Please make checks payable to Kind Mind Counseling Center. There will be a $30 charge for returned checks as non-sufficient funds or non-payable. Credit cards are accepted through Fairview Healthline Billing.
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 Kind Mind Counseling Center 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 Kind Mind Counseling Center (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 Kind Mind Counseling Center, 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 your therapist does need to cancel our appointment, they will either call, text or send an email-whichever you prefer.
Kind Mind therapists do take time away to participate in trainings and vacations. This will be discussed in your sessions.
The standard meeting time for psychotherapy is 45-52 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 218-263-5949. Kind Mind Center therapists are often not immediately available; however, they will attempt to return your call within 48 hours. 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, your therapist does not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). Kind Mind therapists 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
Your therapist 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, do talk with your therapist about this. Your therapist may utilize the Spruce app on a cell phone which offers HIPAA compliant email and messaging. You will need to make an account on your device should you choose this option. While your therapist may try to return messages in a timely manner, Kind Mind Center 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. Your therapist 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. Your therapist may terminate treatment after appropriate discussion with you and a termination process if your therapist determines that the psychotherapy is not being effectively used or if you are in default on payment. Your therapist 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, your therapist 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 your therapist 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 Kind Mind Counseling Center.