Therapy Consent Forms Consent for Services Acknowledgement* Telehealth Consent Acknowledgement* Telehealth Refusal Acknowledgement* Telehealth Informed Consent Acknowledgement*
Attendance & No-Show Policy
Initial Appointment
At Elite Recovery, we value your time and commitment to the therapy process. In order to provide the best possible care and ensure access for all clients, we have the following attendance policy:
Cancellations: Please provide at least 24 hours’ notice if you need to cancel or reschedule your appointment.
Late Cancellations or No-Show (NCNS): If a client does not attend their first scheduled intake appointment (no-show or cancels with less than 24 hours' notice), they will either:
Be placed at the bottom of the therapy waitlist , or
Be required to wait 30 days before scheduling a new appointment.
Late Arrival: If you arrive 20 minutes or more late, the session will need to be rescheduled. This will be documented as a missed appointment under the attendance policy listed above.
This policy helps us open appointment times for other clients waiting for services. We understand that emergencies may arise. Exceptions to this policy may be made at the discretion of your provider or clinic administration.
Ongoing Appointments
To maintain consistent care and ensure availability for all clients, we ask that you provide at least 24 hours’ notice if you need to cancel or reschedule your appointment.
First late cancellation or no-show: One occurrence is allowed without impact to your scheduled services.
Second late cancellation or no-show: You will lose your reserved appointment time on the therapist’s calendar and may need to schedule on a week-to-week basis, depending on availability.
Third late cancellation or no-show: You will either:
Be placed at the bottom of the therapy waitlist, or
Be required to wait 30 days before scheduling a new appointment.
Late Arrival: If you arrive 20 minutes or more late, the session will need to be rescheduled. This will be documented as a missed appointment under the attendance policy listed above.
We recognize that emergencies and unexpected events happen. Exceptions may be made at the discretion of your provider or clinic administration.
Please note: If your therapist needs to cancel or reschedule, this will not count against your attendance record or impact your ability to continue services.
Attendance Acknowledgement*
Financial Agreement & Assignment of Benefits
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 satisfied 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.
Financial Agreement* Financial Agreement Acknowledgement* Complaints, Grievances, or Alleged Rights Violations Acknowledgement* Services Acknowledgement*
HIPAA Notice of Privacy Practices
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 involved in your care and treatment for the purpose of providing health care services, 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 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.
Healthcare Operations
We may use or disclose your protected health information to support the business activities of the clinic. These include quality assessment, employee review, training of students or interns, licensing, and conducting other business activities. We may disclose information to graduate students under supervision, call you by name in the waiting room, contact you for appointment reminders, or inform you about treatment alternatives or other health-related benefits and services.
We may also use or disclose your PHI without your authorization in situations required by law, such as public health issues, communicable diseases, abuse or neglect, legal proceedings, organ donation, research, criminal activity, military activity, national security, workers’ compensation, inmates, and other required uses.
We may disclose health information to our business associates (e.g., billing services). All business associates are required to protect your privacy and comply with HIPAA standards.
Other Permitted Uses and Disclosures Requiring Your Authorization
Most uses and disclosures of psychotherapy notes
Uses and disclosures for marketing purposes
Disclosures that constitute a sale of your protected health information
You may revoke authorization at any time in writing, except to the extent your provider or the clinic has already acted in reliance on it.
Your Rights
You have the right to inspect and copy your PHI (fees may apply), with certain exceptions such as psychotherapy notes and research information.
You have the right to request an electronic copy of your record if maintained electronically.
You have the right to request restrictions on uses and disclosures of your PHI.
You have the right to request confidential communications via alternative means or locations.
You have the right to request amendments to your PHI.
You have the right to receive an accounting of certain disclosures.
You have the right to receive Breach Notifications.
Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated. To file a complaint with us, contact:
Stephanie GoodeStephanie.Goode@horowitzhealth.com
We will not retaliate against you for filing a complaint. We are required by law to maintain the privacy of PHI and provide individuals with this notice of our legal duties and privacy practices. For questions, contact our HIPAA Compliance Officer in person or by phone at our main office number.
Acknowledgement*
