Intake Consent

1. GENERAL CONSENT FOR TREATMENT.

I request that Central Minnesota Mental Health Center (CMMHC) furnish services to the above-named client. I have been informed that I may receive a copy of the CMMHC Intake Packet, including the Minnesota Patient Bill of Rights and information regarding healthcare and psychiatric advanced directives.

45 CFR $164.506 allows CMMHC to use your information for treatment, payment, and healthcare operations. Below are some examples of how we will utilize your information, (please note this list is not all inclusive. Please see CMMHC's Notice of Privacy Practices for more information)

2. BILLING RESPONSIBILITY AND RELEASE.

A. I authorize CMMHC to disclose the client's records to third-party payer(s) (for example, Minnesota Medical Assistance, the county of financial responsibility, insurance company, or a designated care management organization) for the purposes of payment, which may include mental health and substance use disorder (SUD) information. Records may be released orally, in writing, or electronically. B. I hereby authorize any such third-party payer or insurance company to reimburse CMMHC directly for services rendered to the client.

C. I accept full responsibility for notifying CMMHC immediately of any changes in insurance coverage or any third-party payer while receiving services.

D. If I provide insurance coverage information, I understand that the full cost of services and the client's amount of financial responsibility cannot be determined until the client's insurance company processes the claim. I understand that clients are responsible for the full cost of services provided at CMMHC. I accept financial responsibility for all charges not paid by any third-party payer for services provided to the client.

Please seek consultation if you have questions regarding the financial responsibility of guardians. Where appropriate guardians should assist clients with paying bills utilizing client funds or governmental benefits.

E.I understand that if the client's balance is unable to be paid in full, I must contact CMMHC to set up payment arrangements. I also understand that I may be eligible to apply for a reduced rate through CMMHC's Sliding Fee Scale (income limits may apply A Sliding Fee Application must be completed prior to the receipt of services and any documents required by CMMHC, including verification of gross income, is required within thirty (30) days of the Sliding Fee Application.

3. COORDINATION of CARE.

A. CMMHC coordinates care within our agency for all services and across all programs. We follow HIPAA and all applicable federal and state laws regarding confidentiality, including abiding by the minimum necessary standards.

B.CMMHC is a provider within the EpicCare Link Network with CentraCare Health and North Memorial. If the client was referred to CMMHC by one of these providers, CMMHC providers may be able to access view only records from CentraCare Health and North Memorial. If you would not like CMMHC to have access to the client's records within EpicCare Link, please contact CentraCare Health or North Memorial, respectively.

C. CMMHC values health integration; therefore, we believe it is important to address both physical and mental health together and would like to coordinate with the client's Primary Care Provider (PCP If you consent to coordination, please complete an Authorization for Disclosure (ROI) and CMMHC will send a letter to the client's PCP.

D. CMMHC may utilize PointClickCare (PCC), to coordinate care and enhance patient experience for clients who receive state or county benefits. PointClickCare (PCC) allows providers to coordinate care across health care entities and will provide alerts in real time to providers when individuals they provide services to have been admitted, discharged, or transferred from a PCC-participating hospital, emergency department, care facility, or other provider organization. To opt out of PointClickCare (PCC), you may visit their website at www.mneas.org/resources.

E. CMMHC may also use resources such as FindHelp to assist clients in finding requested services or referrals and gives CMMHC the ability to connect clients with organizations that provide them.

F. We utilize SimiTree (AFIA) Analytics to assist us with data analysis of client information to improve your patient experience.

G. We utilize ELEOS software to aid in consistent notetaking/ documentation of our client visits.

4. TELEHEALTH.

The telehealth service model allows for the delivery of mental health and psychiatry services when client(s) and providers are in different locations. I hereby consent to CMMHC providing mental health and psychiatry services to the client via a HIPAA Compliant telehealth platform. I understand the unique risks and benefits associated with telehealth and understand clients may discontinue telehealth services at any time.

5. EMAIL AND OTHER ELECTRONIC METHOD CONTACT.

A. When you provide CMMHC with a telephone number or email address, you consent to receiving communication regarding appointments, including but not limited to, prerecorded or artificial calls, text messages, emails, and calls made by an automatic dialing system from CMMHC. You may opt out at any time.

B. Message and data rates may apply, please contact your wireless provider for specific information regarding your text messaging usage and charges.

C. Additional texting and email consents may be required based on the programs and services being provided to you.

6.VIDEO SURVEILLANCE.

I understand that CMMHC utilizes video surveillance on site for the safety of clients, employees, and visitors.

7. BILLING RECORDS.

A. I authorize CMMHC to discuss the client's billing records with the following people:

 

8.NON-CREDENTIALED PROVIDERS.

I have been informed that if I see a provider that is not currently credentialed with my insurance company, the services will be provided under the supervision of a fully credentialed provider within my insurance network. I will contact my insurance company for further information if needed. CMMHC will follow all applicable billing rules when this applies.

9. *Disclaimer.

Clients must agree to all terms and conditions set forth in this consent. We will not accept consents that have been modified with elements crossed out, or written in.

10. ATTESTATION.

I attest that I am the client or the parent/guardian of the above-named client. I hereby authorize CMMHC to furnish services to the client. I understand that the specific services to be performed, treatment goals, frequency, and estimated length of treatment will be established following an appropriate assessment.