1. GENERAL CONSENT FOR TREATMENT.

A. I confirm that I am requesting services and have received/been offered a copy of the Intake Packet including the  Minnesota Patient Bill of Rights, and Advance Directive Information (as applicable).

2. BILLING PAYER RELEASE.

A. I authorize CMMHC to release all Mental Health and/ or Substance Use Disorder (SUD) information electronically, on paper, or orally to my third-party payer(s) (e.g., Medical Assistance, county of financial responsibility, insurance company, designated care management organization, Prior Authorization, etc.)

B. I hereby authorize, from this day forward, any insurance company to whom I subscribe to pay directly to CMMHC for services rendered to me and/or my dependents.

C. I accept full responsibility for notifying CMMHC immediately of any changes in my insurance coverage while receiving care. If I provide insurance coverage information, I understand that my financial responsibility cannot be determined until my insurance company processes the claim. Failure to provide insurance coverage information will result in me being fully responsible for the bill.

D. I understand that if I cannot pay my balance in full, I am able to set up payment arrangements. I also understand that I may be eligible to apply for a reduced rate through Sliding Fee Scale (income limits may apply) Sliding Fee Application needs to be completed prior to the service and required documents/ verification of gross income is required within 30 days of application.

3. COORDINATION OF CARE.

A. CMMHC coordinates care within our agency for all programs. We follow HIPAA guidelines regarding confidentiality and abide by minimum necessary standards.

B. If you are a CentraCare Health patient, you consented to coordination of care with all providers in the Epic Care Link Network. CMMHC is a provider within the Epic Care Link Network.

C. We value Health Integration; therefore, we would like to coordinate with your Primary Care Provider (PCP) to address both physical and mental health together. Please complete an Authorization for Disclosure (ROI) to send a letter to your PCP if you are okay with this.

D. The Minnesota Department of Human Services has advised that every indvidual who obtains benefits through the Department, both Medical Assistance and Minnesota Care, is deemed to have provided consent for their information to be exchanged via Encounter Alert Service (EAS) through enrollment.

4. TELEHEALTH.

A. 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 me via a HIPAA Compliant telehealth platform.

5. EMAIL AND OTHER ELECTRONIC METHOD CONTACT.

A. When you provide CMMHC a telephone number or email address, you consent to receiving communication, including but not limited to, prerecorded or artificial calls, text messages, emails, and calls made by an automatic dialing system from CMMHC or an agent regarding care.

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

6. VIDEO SURVEILLANCE.

A. I understand that my encounter at CMMHC may be subject to video surveillance for the safety of clients, employees, and visitors.

7. BILLING RECORDS.

A. I authorize CMMHC to discuss my billing records with the following people.

8. NON-CREDENTIALED PROVIDERS.

A. 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.

9. ATTESTATION.

A. I attest that I am the client, parent, and/ or guardian and I hereby authorize CMMHC to provide treatment to the above-named client. I understand that the treatment goals, frequency, and estimated length of treatment will be established following the diagnostic assessment (if necessary). I accept financial responsibility for all charges not paid by my insurance for services provided to me or any other individual that I serve as the guarantor/ responsible party.

10. EXPIRATION.

A. This consent will expire one-year from the date signed or sooner if guardianship changes.