Send your intake and any documnet to : earlysuccesstherapyservices@gmail.com

 

 Early Success Therapy LLC

1710 North Douglas Drive SUITE # 224E, Golden Valley, MN 55422

 Phone Numbers 612-605-1554 ,  612-644-5866.

The above information is true to the best of my knowledge. I authorized my insurance
benefit be paid to the physician . I understand that I am financially responsible for any
balance.
I also authorized Early Success Therapy LLC or insurance company to release any
information required to process my claims.

RIGHTS AND RESPONSIBILITIES OF PROGRAM PARTICIPANTS
At Early Success Therapy, we are committed to providing respectful, ethical, and effective Adult Rehabilitative Mental Health Services (ARMHS). Please review your rights and responsibilities as a program participant:

Participant Responsibilities
Treat staff and other participants with the same courtesy you expect.
Respect the individuality of others, including their ethnic, social, religious, and psychological well-being.
Privacy and Confidentiality
You have the right to privacy and confidentiality under HIPAA and applicable state and federal laws.
Exceptions include:

If you are a danger to yourself or others
If you are gravely disabled and unable to care for yourself
In cases of child abuse or suspected child abuse
If meetings occur in public, every effort will be made to protect your privacy.
Your case may be discussed with a supervising therapist to ensure the best care.
Rights to Information and Choice
You have the right to request and receive information about ARMHS and the goals of your services.
You may request explanations for any referral recommendations.
You have the right to seek a second opinion or refuse services.
You may contact your counselor at any time during your participation.
Professional Boundaries
Sexual intimacy in a professional relationship is never appropriate. Such conduct should be reported to the State Grievance Board.
Governing Boards and Complaints
Mental health services are regulated by Minnesota State Boards:

Board of Psychology: 612-617-2230
Board of Marriage & Family Therapy: 612-617-2220
Board of Nursing: 612-617-2270
Board of Social Work: 612-617-2100
Board of Behavioral Health: 612-548-2177
For other credentialed staff, contact AFID INC or Early Success Therapy for guidance.
Team Approach to ARMHS
ARMHS uses a team model including Mental Health Practitioners, Lead Practitioners, Professionals, and Nurses.
If your assigned practitioner is unavailable, a new practitioner will be promptly assigned to maintain continuity.
No Show / Cancellation Policy
Provide at least 24 hours’ notice for cancellations.
More than three cancellations may result in case closure.
Arrive within 15 minutes of your appointment; otherwise, the session may be canceled.
Crisis Intervention
Follow your current crisis plan or contact:

Crisis Connection (Twin Cities Metro): 612-379-6363
Crisis Connection (outside metro): 866-379-6363
National Suicide Prevention Hotline: 800-273-8255
Or dial 911 in emergencies.
Attestation and Consent
Throughout your treatment, verbal consent will be requested for all treatment plans.
Signing below confirms you have received, read, and understood this statement, including HIPAA/Notice of Privacy Practices and Minnesota client rights.
You acknowledge that Early Success Therapy may release records to your insurance for payment.

At Early Success Therapy LLC, we respect your privacy and are committed to protecting your medical information. This notice explains how we may use and disclose your protected health information (PHI) and how you can access this information. Please read it carefully.

1. Permitted Uses and Disclosures
Early Success Therapy LLC may use or disclose your medical information without your written consent for the following purposes:

Treatment: Sharing information with other health care providers involved in your care, such as attending physicians.
Payment: Submitting claims and supporting documentation to Medicare, Medicaid, or other insurance providers responsible for paying for services.
Health Care Operations: Sharing information with supervisors or administrative staff who oversee your care and conduct quality assurance, training, or other operational functions.
2. Other Permitted or Required Disclosures Without Consent
Your protected health information may also be used or disclosed without your written authorization in situations including, but not limited to:

Reporting to the Secretary of the U.S. Department of Health and Human Services when required by law.
Public health activities and investigations.
Reporting abuse, neglect, or domestic violence.
Health oversight activities.
Judicial or administrative proceedings.
Law enforcement purposes.
Handling deceased individuals’ information for organ or tissue donation.
Research purposes under strict protocols.
Preventing serious threats to health or safety.
Specific government functions.
Disclosures to business associates supporting Early Success Therapy LLC.
Notifications to personal representatives and workforce members who are victims of crimes.
Workers’ compensation programs.
Involvement in your care or for notification purposes.
Situations when you are present or not present for limited uses.
Disaster relief efforts.
3. Uses and Disclosures Requiring Written Authorization
Other uses, such as releasing psychotherapy notes, marketing activities, or selling protected health information, require your written authorization. You have the right to revoke this authorization at any time.

4. Contact for Scheduling and Care Coordination
We may contact you to schedule appointments or coordinate your care.

5. Your Rights Regarding Restrictions
You have the right to request restrictions on certain uses and disclosures of your protected health information. While Early Success Therapy LLC is not required to agree to your request, we will comply if the disclosure is to a health plan for payment or health care operations and you have paid in full for the related service.

I authorize Early Success Therapy LLC staff to render Mental Health Services in my home or community as ordered by my Mental Health Professional and as outlined in my Plan of Care.
All services to be provided by Early Success Therapy LLC have been fully explained to me and documented in a Service Agreement.
I understand that my Plan of Care may change as necessary, and any changes will be discussed with me in advance. Care instructions have been explained and, as stated in the Service Agreement, will become my responsibility in the absence of staff.

Release of Information:
I authorize my medical information to be released to authorized representatives of Medicare, Medicaid, or other designated insurance carriers for purposes of determining care benefits payable to Early Success Therapy LLC for services provided.
I also authorize any hospital, clinic, physician’s office, or healthcare facility I have used to release any or all of my medical records, including Health Care Directives, to Early Success Therapy LLC.
In addition, I permit the release of part or all of my medical records to agencies or medical equipment vendors involved in providing services coordinated by Early Success Therapy LLC.

Request for Payment:
I request payment of authorized Medicare, Medicaid, or other insurance benefits and assign these benefits directly to Early Success Therapy LLC.
If payment is denied, I acknowledge my financial responsibility for services rendered.
If prior authorization is required by my insurance provider, Early Success Therapy LLC may wait until such approval is received before starting services.
Should I choose to begin services before authorization is obtained, I accept responsibility for potential costs.

Acknowledgment of Rights:
I acknowledge that I have been informed of my rights under State and Federal law as outlined in the Bill of Rights. I confirm that I have received a copy.

Certification:
I agree to all the conditions stated above and certify that I am the client or the client’s legal representative and am capable of executing this agreement.
I understand that this agreement may be revoked at any time by either party.