Authorization To Disclose Information For Insurance Purposes

I authorize information in my medical record to be released to authorized representatives of my medical insurance for the use of determining benefits and services payable to Transformation House on my behalf.

I request that my medical insurance submit payment on my behalf to Transformation House. I understand that I will be responsible for any amount not covered by my medical insurance including insurance deductibles and co-pays.

By signing this form I understand that I have given permission for an exchange of information to occur. My signature indicates that I know what information will be given and what it will be used for. This authorization further states that I know who will receive/exchange information and that this information is private.

Telemedicine Policy

Transformation House offers Telemedicine as a form of providing MH/SUD treatment services. Telemedicine has been proven to be as effective as face to face counseling and is an effective way for people to receive treatment services to help manage substance use disorder problems and mental health symptoms, and improve overall mental health. Here at Transformation House our providers have received necessary training to provide Telemedicine services and will go through a process with you to determine if you are a good fit for receiving Telemedicine services. Please note that over time your counselor may determine that you are no longer a candidate to receive such services, or may determine that you are eligible as you work together.

Safety is important to us here at Transformation House. You will need to verify your identity and be willing to follow set guidelines and safety practices to continue any form of counseling at Transformation House.

Transformation House will use a HIPAA compliant, audio and video, two-way interactive website. The client and our provider/counselor will use audiovisual telecommunications technology (computer). This type of service is also referred to as “real-time” and may serve as a substitute for an in-person session. You will need to provide your own computer, have access to email, and know some minor basics about using email. You will be required to have your own email address.

Confidentiality is very important for all of us here at Transformation House, and we will follow all state and federal guidelines and take seriously using equipment that values your privacy.

If you would be interested in receiving Telemedicine services you must complete a Risk Assessment with your counselor to determine if you are a good fit for Telemedicine. You must be willing to comply with standards of practicing safe telemedicine services which include but are not limited to some of the following criteria:

Privacy Measures for the Client - (Expectations of the client):

  • Avoid using mind altering substances prior to session.

  • Dress appropriately.

  • Hold the session in an appropriate room (not a bedroom) when attending a web-based session.

  • Do not have anyone else in the room.

  • Do not conduct other activities while in session.

  • Do not record sessions.

  • Be located within the State in which the clinician is licensed to practice (client should inform the clinician of their location).

  • It is recommended that you sign on to your account at least 5 minutes prior to your session start time. You are responsible

  • for initiating the connection with your provider at the time of your session.

  • With the use of technology, it is important to be aware that family, friends, co-workers, employers, and hackers may have

  • access to any technology, devices, or applications that you use.

  • Do not keep your therapist’s contact information on your phone if it is synced with other accounts/applications.

  • Notify your counselor if you suspect any breach in your security.

Emergency Measures for Telemedicine

So that we can get you help in the case of an emergency and for your safety, the following are important and necessary. In addition, by signing this agreement form you are acknowledging that you understand and agree to the following:

  • You, the client, will inform me, your counselor, of the location in which you will consistently be during our sessions, and will inform me if this location changes.

  • You, the client, will identify, on your client information form, a person (Emergency Contact), whom I, your counselor, can contact in the case that I believe you are at risk of harming yourself or others.

  • Depending on my assessment of risk, you, the client, or I your counselor, may be required to verify that your emergency contact person is able and willing to go to your location in the event of an emergency, and if I deem necessary, call 911 and/or transport you to a hospital. In addition, I may assess, and therefore require, that you create a safe environment at your location during the entire time that you are in treatment with Transformation House. This may mean disposing of all firearms and excess medication from your location.

Safety and Client-Provider Relationships

Clients should trust that providers will offer necessary information for clients to make decisions about treatment. They should also expect competent care, assurance of privacy and confidentiality, and continuity of care. Providers’ ethical responsibilities remain the same with telemedicine, but differences in possible client-provider interactions in telemedicine have brought accountability and the client provider relationship to the forefront in discussions about telemedicine safety. As an avenue for service delivery, telemedicine ideally would be integrated into regular, coordinated care and services.

 

Discontinuation of Telemedicine Services

Each Alcohol and Drug Counselor and Mental Health Professional at Transformation House will access and discuss treatment to determine if in-person services, telemedicine services or a combination of the two would be most appropriate. Discontinuation of any of these services will be determined based on clinical judgement of treatment plan adherence, and/or treatment progress towards goals identified. Once a client has reached their goals according to their treatment plan the clinician and client will work together towards discharge, or work toward creating a new treatment plan based on clinical necessity.

If you are interested in receiving Telemedicine services you must read and sign this document and complete a RISK ASSESSMENT (Telemedicine Assessment Client Fit). If done electronically they will be entered into your electronic clinical record. If you complete them in the office, please return them to your counselor.

Patient’s Right to Privacy Practices/HIPAA

I acknowledge that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: conduct, plan, and direct my treatment and follow-up care among providers who may be involved in that treatment directly and indirectly and to obtain payment from third party payers (a list is available upon request). If I would like a copy of Agape’s privacy form, I will ask for one. I understand that my health records will not be used for research without my permission as described in the Privacy Notice. However, for the purpose of improving Agape’s services and program planning, my health data may be used in aggregate by the program for evaluation purposes. I understand that my health information is protected by federal regulation (Alcohol and Drug Abuse Patient Records, 42 CFR Part 2:

and/or HIPAA 45CFR) and state privacy laws, and disclosure is allowed only with my authorization except in limited circumstances described in Agape’s Privacy Notice.

I can revoke this authorization at any time except to the extent that action has been taken in reliance on it. Agape’s notice outlines the procedure for revocation. This authorization will expire when I terminate services with Agape or unless I request an earlier expiration in writing.

For disclosures other than for medical, mental health, and laboratory services, payment and healthcare operations purposes, care may not be conditioned on my agreement to sign and authorization (unless I am receiving care solely to create protected health information for disclosure to a third party) (45 CFR & 164.508(b)(4)(III)).

Minnesota Adult Abuse Reporting Center

Transformation House employees are mandated reporters. If any form of abuse, neglect or financial exploitation of a vulnerable adult has occurred we are required to report it. The Minnesota Adult Abuse Reporting Center (MAARC) Mandated Reporter Form is a web­ based reporting system available 24/7 for mandated reporters to meet requirements for civil reporting of suspected maltreatment of vulnerable adults.

Mandated reporters are professionals identified by law (MS626.5572 Subd.16) who are required to make a report if they have reason to believe that abuse, neglect, or financial exploitation of a vulnerable adult has occurred. Mandated reporters have not met their duty to report until the report has been submitted and the report number is provided. If a report needs to be made, anyone can contact MAARC 24/7 by calling:

MAARC - Adult Abuse Reporting 1-844-880-1574

Client Acknowledgement

By checking the box in the Intake Form and typing my signature, I acknowledge that I have read, understood, and agree to all the information, policies, disclosures, and authorizations provided on this page, including but not limited to:

  • Authorization to disclose information for insurance purposes

  • Telemedicine policies and procedures

  • Emergency measures and safety protocols

  • HIPAA privacy practices

  • Minnesota Adult Abuse Reporting requirements

I understand that this acknowledgment applies to all pages and sections of this document. I affirm that I have had the opportunity to ask questions about this information and have received answers to my satisfaction.

I understand that my typed signature is valid as my legally binding signature pursuant to applicable federal and state laws, including the Electronic Signatures in Global and National Commerce (E-SIGN) Act and the Uniform Electronic Transactions Act (UETA). By electronically signing the intake form, I agree that my typed name and/or electronic indication of signature has the same legal effect as a handwritten signature.