Therapy Consent Forms
Guarantee of Account
I agree to pay Elite Recovery for all charges for services not covered by a third-party payer. I understand that I am responsible for complying with my insurance company's rules and regulations regarding pre-certification and pre-authorization requirements. I agree that if preauthorization of services is required, unauthorized visits will be my responsibility for payment. Elite Recovery will assist in keeping track of the sessions used.
Insurance Consent
I request that payment of authorized benefits be made directly to Elite Recovery, including the clinic's participating clinicians (such as mental health professionals [MHPs], interns, physicians, and psychiatric nurse practitioners [PNPs]), for any services provided. I authorize Elite Recovery to release medical or financial information to payers as needed for claims processing, fraud investigations, or quality of care reviews.
Consent for Release of Information (ROI)
I consent to the release of information about my medical condition to any health care provider working for Elite Recovery involved in my treatment. I understand that other clinic staff involved in billing, medical records review, and other necessary duties may also see my medical records. I further understand that staff may contact me to seek my opinion about the helpfulness of services I received or problems I encountered.
Consent for Trainees
I am aware that I may be attended by staff in training under the supervision of a licensed provider.
Services Provided
I understand that mental health (MH) and psychiatric services may be provided through two-way interactive video communications and/or electronic transmission of information, known as "telehealth" or "telemedicine." This means that I will receive evaluation and treatment from a provider located remotely. Given the unique nature of telehealth, I agree to the following terms:
1. The provider will be located at a different site than me. I will connect to remote services from either the clinic or another private and comfortable location within the State of Minnesota (MN).
I will identify and sign a release of information (ROI) form for an emergency contact (EC) who will be available in close physical proximity during all telehealth sessions in case of an emergency. I will provide my provider with the contact information for this person.
2. I will be informed if any additional staff, such as a trainee, will be present during the session and will have the option to decline.
3. Video recordings of the telehealth session may be taken with my written permission. These recordings may be retained, viewed, and used for teaching, training, technical assistance, or administrative purposes.
4. In case of technical issues, I can directly contact my provider. They will assist me in resolving the problems or transfer me to appropriate support.
Billing is performed by the business office of Elite Recovery, LLC located at 937 Grand Avenue, Saint Paul, MN 55105. Additional services are provided by Hometown Billing of Hibbing, MN. A description of fees and costs of services is given to each client at the initiation of services. If you need another copy, please request one.
This is a behavioral health-funded (BHF) program licensed by the State of Minnesota, and all our participants receive funding through the behavioral health block grant fund, private insurance, or self-pay. BHF clients are not responsible for the partial payment of services.
Financial Agreement
You agree to pay your Elite Recovery, LLC bill in full within 30 days of service. Charges will reflect our standard rates or the negotiated rate with your insurance provider. Accepted payment methods include cash, check, major credit cards (Visa, MasterCard, American Express, Discover), and HSA/FSA debit cards. If your account requires collection efforts, you are responsible for all related costs, including attorney fees, court costs, and collection agency fees, unless prohibited by law.
Insurance Submissions & Agreement of Benefits
As a courtesy, we will bill your insurance provider for services. By signing this agreement, you authorize Elite Recovery, LLC to apply for payment on your behalf from Medicare, Medicaid, or any private insurance. You confirm the accuracy of the insurance information you provided and authorize payment of benefits directly to Elite Recovery, LLC. You also assign to us any rights to insurance, benefits, settlements, or judgments related to your care. You remain financially responsible for any charges not covered by your insurance and for meeting any requirements your insurance plan may have.
Co-Payment Collection
Per your contract with your insurance company(s), all co-payments must be satis?ed during each and every visit. There can be no exceptions due to legally binding contracts and uniform compliance rules.
Insurance Plan Restrictions
It is your responsibility to verify your insurance benefits, including coverage, exclusions, referral requirements, and whether Elite Recovery is in-network. Some plans reduce or deny payment for out-of-network services. You are responsible for all copays, deductibles, and charges not covered by your plan. Insurance companies do not guarantee payment, and any cost estimates provided are based on the best available information. If we do not receive a response from your insurer, we may contact you for assistance. Payment plans must be approved by our business office.
We work with many insurers, including BlueCross BlueShield, HealthPartners, Cigna, United Behavioral Health/Medica, United Healthcare, Aetna, Medical Assistance, UCare Minnesota, Hennepin Health, South Country Health Alliance, PrimeWest Health and more.
Secondary Insurance & Coordination of Benefits Having multiple insurers does not guarantee full coverage. Secondary insurers have specific rules for coordinating with your primary insurance. We bill both as a courtesy, but you are responsible for any remaining balance. If your secondary insurance has not paid within 45 days, the balance may become your responsibility.
Returned Checks & Credit Card Denials
Returned checks or denied credit card transactions will incur a $30 fee unless prohibited by law.
Privacy Policy, Client Rights and Responsibilities
Your privacy regarding medical information is of utmost importance to us, and we are dedicated to safeguarding it. A comprehensive record of your care will be established for the services provided during your time as a client at our clinic. This record is essential for delivering quality care and ensuring compliance with regulatory standards. Your medical information may be disclosed to other treating providers at your request, your insurance company to facilitate payment of your claim, and to pharmacies to assist in obtaining your medications. Our complete privacy policy is prominently displayed on the waiting room wall for your reference. Additionally, you are receiving a copy of your rights and responsibilities for your records. By signing this form, I acknowledge that I have read and understood this policy and have been informed of the privacy practices implemented at this clinic.
To file a complaint, you may contact:
Office of Ombudsman for Mental Health and Developmental Disabilities
332 Minnesota St., Ste. W1410
First National Bank Building
St. Paul, MN 55101
(651) 757-1800
Ombudsman.MHDD@state.mn.us
Minnesota Department of Health Office of Health Facility Complaints
(651) 201-4200
Health.FPC-Web@state.mn.us
Minnesota Department of Human Services
540 Cedar St. St. Paul, MN 55101
(651) 431-2000
Health.FPC-Web@state.mn.us
After Hours Emergencies
In the event of an after-hours emergency, I understand that I can contact the clinic and follow the instructions provided on the recording. Additionally, I am aware that there are resources available for crisis assistance that I can refer to if needed.
Telephone
If Elite Recovery staff need to contact you for purposes such as appointment cancellations, reminders, or to exchange other information, we will make every effort to maintain confidentiality. By default, we will call your primary contact number and request to speak with you without disclosing our identity. If needed, we will identify ourselves as your therapist or provider's representative, but we will not reveal our name or specify the nature of the call unless instructed otherwise. Please provide any additional instructions you would like us to follow.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected Health Information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services.
Uses & Disclosure of Protected Health Information
Your protected health information may be used and disclosed by your provider(s), our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the clinic, and any other use required by law.
Treatment
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.
Payment
Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations
We may use or disclose, as-needed, your protected health information in order to support the business activities of the clinic’s practice. These activities include, but are not limited to, quality assessment, employee review, training of students or interns, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to graduate students under the clinical supervision of licensed providers that see clients at our clinic. We may also call you by name in the waiting room when your provider is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law, public health issues as required by law, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, workers’ compensation, inmates, and other required uses and disclosures.
Under the law, we must make disclosures to you upon your request. Under the law, we must also disclose your protected health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under Section 164.500.
We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and abide by the same HIPAA Privacy standards as outlined in this Notice of Privacy Practice.
Other Permitted Uses and Disclosures Requiring Your Authorization
Unless noted above in our Use and Disclosures, all other permitted uses and disclosures of your protected health information will be made only with your consent, authorization or opportunity to object unless required by law. This includes:
Most uses and disclosure of psychotherapy notes.
Uses and disclosure for marketing purposes.
Disclosures that constitute a sale of your protected health information.
You may revoke the authorization, at any time, in writing, except to the extent that your provider or the clinic has taken an action in reliance on the use or disclosure indicated in the authorization.
Your Rights
The following are statements of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information (fees may apply) – Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of confidentiality.
If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form.
We have up to 30 days to make your Protected Health Information available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state of federal needs-based benefit program.
You have the right to request a restriction of your protected health information – This means you may ask us not to use or disclose any part of your protected health information and by law we must comply when the protected health information pertains solely to a health care item or service for which the health care provider involved has been paid out of pocket in full. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices.
Your request must state the specific restriction requested and to whom you want the restriction to apply. By law, you may not request that we restrict the disclosure of your PHI for treatment purposes.
You have the right to request to receive confidential communications – You have the right to request confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.
You have the right to request an amendment to your protected health information – If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures – You have the right to receive an accounting of all disclosures except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of this request.
You have the right to receive a Breach Notification. You have the right to receive a notification upon a breach of any of your unsecured Protected Health Information. You have the right to obtain a paper copy of this notice from us even if you have agreed to receive the notice electronically. We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment. We will also make available copies of our new notice if you wish to obtain one.
Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Vice President of Recovery Services of your complaint. We will not retaliate against you for filing a complaint.
Stephanie Goode
Vice President of Recovery Services
Stephanie.Goode@horowitzhealth.com
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect. If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.
