Client Informed Consent for Treatment and Privacy Practices

Welcome to Mending Mental Health. We are committed to providing compassionate, patient-centered psychiatric and mental health care in a professional, structured, and collaborative environment.

This document outlines the nature of services, my rights and responsibilities, and important policies governing treatment. Please read it carefully and ask questions about anything that is unclear.

Nature and Purpose of Services

Mending Mental Health provides outpatient psychiatric and mental health services, which may include:

• Psychiatric evaluations

• Diagnostic assessments including testing

• Medication management

• Psychotherapy

• Consultation and coordination of care

Treatment is individualized and based on clinical assessment, medical necessity, and professional standards of care. Recommendations may include therapy, medication, referrals, diagnostic testing, or coordination with other providers.

Mental health treatment is a collaborative process. Active participation, honest communication, and adherence to agreed-upon treatment recommendations are essential components of effective care.

While we strive to provide high-quality, evidence-based treatment, outcomes cannot be guaranteed. Response to treatment varies from person to person.

Voluntary Participation

Participation in treatment is voluntary. You may decline specific recommendations or discontinue services at any time. We request that you communicate openly with my provider before ending treatment so that appropriate clinical recommendations or referrals can be discussed.

Providers may also determine that services should be modified, transferred, or terminated if treatment is no longer clinically appropriate, if attendance patterns disrupt care, or if safety or ethical standards cannot be maintained.

Risks and Benefits of Treatment

Mental health treatment may offer significant benefits, including improved mood stability, reduced symptoms, increased insight, stronger coping skills, improved relationships, and greater overall functioning. Many individuals experience meaningful growth and increased confidence as treatment progresses. However, treatment can also involve risks. Discussing difficult experiences, trauma, or emotional patterns may temporarily increase distress. Symptoms may fluctuate during medication adjustments or therapeutic processing. Psychiatric medications, when prescribed, may carry potential side effects or require careful monitoring. While treatment is designed to support improvement and safety, outcomes cannot be guaranteed, and progress varies from person to person. Your provider will review specific risks and benefits relevant to my care plan and answer any questions I may have.

Provider Responsibilities

Providers are responsible for delivering care consistent with professional, ethical, and legal standards. This includes conducting appropriate evaluations, developing a structured and individualized treatment plan, monitoring clinical progress and safety, and maintaining appropriate professional boundaries. Your provider will make recommendations based on clinical judgment and established standards of care, and will communicate openly about treatment options, risks, and alternatives. Confidentiality will be protected in accordance with state and federal law. Providers also have an ethical obligation to ensure that care is delivered within a consistent and clinically appropriate framework and may modify or terminate services if necessary to maintain safety, compliance, or treatment integrity.

Client Responsibilities

Effective mental health treatment requires active participation. As a client, I agree to provide accurate and complete information about my medical history, mental health history, current symptoms, and all medications, including controlled substances prescribed by other providers. I agree to notify my provider of significant changes in my health status, treatment with other professionals, or changes in medication. I agree to engage honestly in the treatment process, attend scheduled appointments as outlined in practice policies, and follow through with agreed-upon treatment recommendations. Withholding critical information or providing inaccurate information may compromise safety and limit my provider’s ability to deliver appropriate care.

Disclosure of Medical History and Medication Information

Safe psychiatric care depends on full and accurate disclosure of my medical and mental health history. I agree to provide truthful and complete information regarding prior diagnoses, treatments, hospitalizations, and all current or past medications. This includes disclosure of all controlled substances prescribed by any provider, including stimulants, opioids, benzodiazepines, ketamine, buprenorphine products, methadone, and other scheduled medications.

I also agree to disclose relevant history of substance use, medical conditions, and treatment received from other healthcare professionals.

Failure to provide accurate information may compromise clinical safety and may result in modification or termination of services if my provider determines that safe treatment cannot be maintained.

This policy exists to protect my safety and ensure that care is delivered responsibly and ethically.

Notice of Confidentiality & Privacy Practices

Privacy is important to us. Mending Mental Health protects health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and applicable Minnesota law. Information shared in treatment is generally confidential and will not be disclosed without a written authorization, except in circumstances required or permitted by law.

Information may be used or disclosed for purposes of treatment coordination, payment processing, healthcare operations, and legal or regulatory compliance. This may include communication with other providers involved in your care, submission of insurance claims, quality improvement activities, audits, or regulatory oversight.

There are specific situations in which confidentiality may be legally or ethically limited. These include:

• suspected abuse or neglect of a child, elder, or vulnerable adult;

• credible threats of harm to myself or others;

• court orders or subpoenas;

• insurance claims processing, audit responses, or case reviews;

• emergency situations such as natural disasters that risk record loss;

• regulatory requirements by licensing boards or compliance with the US Freedom Act;

• observations and consultations; and

• any other disclosures mandated by federal, state, or local law.

If such a situation arises, your provider will disclose only the minimum information necessary and will discuss the disclosure with I when appropriate and feasible. For training and quality improvement, Mending Mental Health may engage peer or supervisory observation. Patients will be informed and obtained consent before any observation.

We utilize secure electronic health record systems and business associates who are contractually obligated to safeguard information. While we implement reasonable safeguards to protect privacy, no electronic system can guarantee absolute security.

I acknowledge that I have received and reviewed the Notice of Confidentiality & Privacy Practices.

Your Privacy Rights

You have specific rights regarding my protected health information. You have the right to request limits on certain uses or disclosures of my information, to choose my preferred methods of communication, and to request that we communicate with you in a confidential manner. You may request to review or receive copies of my health information, or to have copies transferred to another healthcare provider. You may also request corrections or amendments to my record if you believe information is inaccurate or incomplete. If we do not agree with the requested amendment, written request will be included in your record.

You may request a copy of this Notice of Privacy Practices at any time. If material changes are made to this notice, an updated version will be provided in writing and made available to you.

Complaints and Contact Information

Our services are voluntary, and we encourage open communication. If you have concerns, please contact a supervisor at Mending Mental Health. Filing a complaint will not affect care or access to services. If you believe privacy rights have been violated, you may contact the Co-Owner, Operations Director at Mending Mental Health to discuss concerns.

Contact Information

Co-Owner, Operations, Mending Mental Health

Leah Clausen

Email: lclausen@mendingmh.com Ph: 612-488-0040

Additionally, formal complaints can be filed with:

• MN Dept. of Human Services

• MN Dept. of Human Rights

• U.S. Department of Health and Human Service

Communication & Electronic Communication

We may communicate with you regarding appointments, billing, treatment coordination, medical updates, medications, pharmacy/prior authorization, or administrative matters by phone, secure patient portal, text, or other agreed-upon methods. You may request preferred communication methods, and we will make reasonable efforts to accommodate those preferences.

Email and standard text messaging are not fully encrypted forms of communication. While Mending Mental Health has an encrypted system, that may not be true for your personal accounts. We strive to minimize risk; however, electronic communications carry inherent privacy limitations. By choosing to communicate electronically, I acknowledge and accept these risks.

SMS & Electronic Communication Consent (Enhanced PHI Disclosure)

You may elect to receive communication from Mending Mental Health by text message (SMS). By providing your mobile phone number and signing this consent, I authorize us to communicate with me by SMS regarding my care.

I understand that text messaging is not a fully secure or encrypted form of communication, and there is a risk that protected health information (PHI) could be accessed by unauthorized individuals if my phone is lost, shared, or otherwise compromised.

I specifically consent to receiving treatment, payment, and healthcare operations-related information by SMS. This may include medication names, dosages, refill status, prescription coordination, insurance prior authorizations or denials, appointment-related clinical updates, and requests for follow-up information. I understand that communication may include the names of stimulants, opioid, benzodiazepine, or other controlled medications when reasonably necessary for my care or administrative coordination.

Standard messaging rates may apply, and message delivery cannot be guaranteed to be private or timely. I may withdraw this consent at any time in writing or by replying STOP to a text message. Withdrawal of consent will not affect communications sent prior to the request. Alternative communication methods, including secure portal messaging or phone calls, are available upon request.

I acknowledge that I understand the risks associated with SMS communication and voluntarily choose to receive protected health information via text message. I release Mending Mental Health from liability related to unauthorized access resulting from the inherent limitations of SMS communication, except in cases of gross negligence or willful misconduct.

Audio and Video Recording Policy

Minnesota law permits individuals to record conversations in which they are a participant. However, to protect confidentiality, preserve therapeutic boundaries, and maintain the integrity of the clinical environment, Mending Mental Health requires prior written authorization before any audio or video recording of sessions.

Recording sessions without prior written consent may interfere with treatment, compromise confidentiality, and impact the therapeutic relationship. If unauthorized recording occurs, the provider may determine that continuation of services is no longer clinically appropriate.

Mending Mental Health may engage in supervision or consultation as part of professional development and quality assurance. Any individuals involved in supervision are bound by the same confidentiality requirements. Sessions will not be recorded for training purposes without separate written consent.

Emergency Services

Mending Mental Health does not provide emergency services outside of office hours (8:00 am – 6:00 pm, weekdays). In an emergency, call 911, visit your nearest hospital, or reach a crisis line. Minnesota crisis contacts include:

Minnesota Crisis Line: CRISIS (274747) National Suicide & Crisis Lifeline: 988

Additional local crisis contacts are available upon request.

Minnesota Patients’ Bill of Rights

Mending Mental Health complies with the Minnesota Patients’ Bill of Rights (Minn. Stat. § 144.651). Patients receiving healthcare services in Minnesota are entitled to specific rights, including but not limited to the right to respectful care, the right to information about treatment, the right to participate in care decisions, the right to privacy and confidentiality, and the right to voice grievances without retaliation.

This law outlines your rights as a patient receiving health care services in Minnesota, including but not limited to:

1. Information About Rights

Patients shall, at admission or at the start of treatment, be informed that there are legal rights for their protection during the course of treatment and that these rights are described in a written statement. Reasonable accommodations shall be made for those with communication disabilities and those who speak a language other than English.

2. Courteous Treatment

Patients have the right to be treated with courtesy and respect for their individuality by persons providing service.

3. Appropriate Health Care

Patients shall have the right to appropriate medical and personal care based on individual needs.

4. Provider Identity

Patients shall be given, in writing, the name, business address, telephone number, and specialty, if any, of the physician, advanced practice registered nurse, or physician assistant responsible for coordination of their care.

5. Relationship with Other Health Services

Patients who receive services from an outside provider are entitled, upon request, to be told the identity of that provider and the nature of the services rendered.

6. Information About Treatment

Patients shall be given complete and current information concerning their diagnosis, treatment, alternatives, risks, and prognosis in terms and language they can reasonably understand. They may be accompanied by a family member or other chosen representative. Individuals also have the right to refuse this information.

7. Participation in Planning Treatment

Patients shall have the right to participate in the planning of their health care, including discussing alternatives and involving family members or chosen representatives in treatment planning.

8. Continuity of Care

Patients shall have the right to be cared for with reasonable regularity and continuity of staff assignment as facility policy allows.

9. Right to Refuse Care

Competent patients shall have the right to refuse treatment and to be informed of the likely results of refusal.

10. Freedom from Maltreatment

Patients shall be free from maltreatment, including physical or emotional abuse and non-therapeutic restraints, except in fully documented emergencies.

11. Privacy and Confidentiality of Records

Patients shall be assured confidential treatment of their personal and medical records and may approve or refuse release of their records to any individual outside the practice, subject to law.

12. Responsive Service

Patients shall have the right to a prompt and reasonable response to their questions and requests.

13. Grievances

Patients shall be encouraged and assisted to understand and exercise their rights and may voice grievances or recommend changes in policies and services without restraint, interference, coercion, discrimination, or reprisal.

14. Advocacy Services

Patients shall have access to rights protection services and advocacy services to assist in understanding, exercising, and protecting their rights, including opportunities for private communication with advocacy representatives.

It is the intent of the Legislature and the purpose of this section to promote the interests and well-being of the patients and residents of health care facilities. No health care facility may require a patient or resident to waive these rights as a condition of admission or treatment. Any guardian or conservator of a patient or resident, or in the absence of a guardian or conservator, an interested person, may seek enforcement of these rights on behalf of a patient or resident through administrative agencies or the courts. It is the intent that every patient’s civil and religious liberties, including the right to independent personal decisions and knowledge of available choices, shall not be infringed and that the facility shall encourage and assist in the fullest possible exercise of these rights.

I am committing to the fact that I read, received, and understand these policies, including the Patient’s Bill of Rights, Privacy, Compliance, and Confidentiality outline, and give consent to Mending Mental Health to provide agreed-upon treatment. I understand that my participation is voluntary and that I may discontinue services at any time. My rights to confidentiality, as protected by state and federal laws, include limits for specific situations (e.g., abuse reporting or threats of harm). I am aware of my role in therapy and understand my responsibilities within this partnership.

Telehealth Consent

Mending Mental Health offers telehealth services using HIPAA-compliant audio and video technology in accordance with Minnesota law and applicable payer regulations, including Minnesota Department of Human Services (DHS) requirements.

Telehealth services may include psychiatric evaluations, medication management, therapy, consultation, care coordination, and follow-up services delivered through interactive, real-time communication technology.

Telehealth allows patients to receive services remotely rather than in person. I understand that telehealth involves the use of electronic communications to enable my provider to diagnose, consult, treat, educate, and coordinate care. Telehealth services are considered equivalent to in-person care in terms of clinical standards; however, certain conditions may require in-person evaluation or referral to another provider.

Potential Risks and Limitations

I understand that telehealth carries certain inherent risks, including but not limited to: Technology failures or service interruptions, reduced ability to perform physical examination, potential unauthorized access to electronic communication, delays in response due to technical difficulties.

While Mending Mental Health uses secure, HIPAA-compliant platforms, no technology system can guarantee absolute security.

I agree to provide my current physical location at the beginning of each telehealth session. This is necessary for emergency planning and compliance with Minnesota regulations.

Telehealth services are not appropriate for emergencies. If I am experiencing a medical or psychiatric emergency, I agree to call 911, contact 988, or go to the nearest emergency department. My provider may initiate emergency procedures if there is concern for my safety.

Participation in telehealth is voluntary. I may withdraw consent to telehealth services at any time. However, I understand that some providers at Mending Mental Health primarily deliver services via telehealth. If I withdraw consent for telehealth and in-person services are not available through my assigned provider, continuation of care may not be possible. In such cases, we will make reasonable efforts to provide referrals to appropriate in-person providers.

Withdrawal of telehealth consent will not affect services already provided.

Authorization of SureScripts e-Prescription Network

I hereby authorize Mending Mental Health to share and receive my prescription information electronically through SureScripts, an electronic prescription network. This authorization allows Mending Mental Health to send, receive, and update my prescription records as a part of my treatment.

I understand that this authorization enables my healthcare providers to electronically send prescription information to participating pharmacies and other providers involved in my care. This authorization is voluntary, and I understand that I make revoke it in writing at any time. My revocation will not affect actions taken before the date it was received by Mending Mental Health.

I am aware that my prescription information is protected under applicable privacy laws, including HIPAA, and will only be used or disclosed for my treatment, payment, or healthcare operations, or as required by Law.

Insurance Authorization and Assignment of Benefits

If I choose to use insurance benefits, I authorize Mending Mental Health to release necessary medical information to my insurance provider for the purpose of claim submission, authorization requests, payment processing, and audit compliance. I also authorize my insurance company to assign payment benefits directly to Mending Mental Health.

I agree to provide accurate and current insurance information and to notify the clinic promptly of any changes in coverage. Failure to provide updated or accurate insurance information may result in denied claims and transfer of balances to patient responsibility.

Understanding Insurance Coverage

Insurance coverage is a contract between me and my insurance company. Mending Mental Health will submit claims as a courtesy; however, we cannot guarantee coverage, reimbursement amounts, or claim approval.

I am financially responsible for:

• Deductibles, Copayments, Coinsurance, Non-covered services, and

• Services denied due to lack of medical necessity, authorization requirements, coordination of benefits, or inactive coverage

If a claim is denied and cannot be resolved within 30 days, the balance may transfer to patient responsibility. If I receive payment directly from my insurance company for services provided by Mending Mental Health, I agree to remit that payment to the clinic promptly.

Outstanding balances remain my responsibility regardless of insurance processing status.

Private Pay Services

If accurate and active insurance information is not provided, I will be considered a private pay patient. Payment is due at the time of service unless prior arrangements are made. Accepted payment methods include credit card, debit card, HSA/FSA card, check, or other approved methods. Sliding scale rates may be discussed at intake based on documented financial need and provider availability.

Credit Card on File Authorization

To ensure clear and consistent billing, an active credit or debit card must be maintained on file.

I authorize Mending Mental Health to charge the card on file for:

• Copayments at the time of service

• Deductible and coinsurance amounts after insurance processing

• Patient-responsibility balances

• Late cancellation or No-Show fees (if assessed)

• Administrative fees (e.g., documentation requests)

• Court or legal appearance fees (if applicable)

• Returned check fees ($30/check)

Copays may be charged on the date of service. Insurance-related balances may be charged after claims are processed and patient responsibility is determined. Missed appointment fees may be charged within 1-5 business days of the appointment.

I may receive notice of balances due after insurance processes through my patient portal, and via text from Athena, or from insurance EOBs. Notices in Athena populate 3 days before the card on file is automatically processed. It is my responsibility to update the team with a payment plan if I do not want my card to be run automatically. Billing statements populate for those who do not opt into electronic billing upon check-in; however, my card may still be run for copays and balances due automatically if they are on file. If a card is declined, I agree to update payment information promptly. Repeated declined payments may result in suspension of scheduling and refills until resolved.

Documentation, Reports, and Administrative Requests

Requests for letters, forms, or clinical documentation outside of an appointment may incur fees ranging from

$25 to $250 depending on complexity and time required.

Court Testimony and Legal Proceedings

The therapeutic relationship depends on confidentiality and clinical neutrality. Court appearances or legal testimony are considered exceptional services.

If a provider is required to participate in legal proceedings, the following fees apply:

• Therapist: $250 per hour (eight-hour minimum)

• Medication Prescriber: $400 per hour (eight-hour minimum)

Payment is required two weeks in advance. Cancellations within 72 hours of a scheduled appearance are non-refundable.

Authorization and Notification Requirements

I authorize Mending Mental Health to release any necessary medical information to my insurance provider to process claims. I confirm that the information provided here is accurate to the best of my knowledge.

Additionally, I authorize my insurance provider to assign payment benefits directly to Mending Mental Health.

I agree to promptly inform Mending Mental Health of any changes to my health insurance coverage. I acknowledge that I am responsible for payment of all services provided by Mending Mental Health at the time of service, which includes any applicable deductibles, co-insurance, and co-payments. If treatment is ended or suspended, I understand that all outstanding balances are due immediately, regardless of the claim submission process. I understand that an active credit card must remain on file and that it will be automatically run when balances populate. If I would like to change this to a payment plan, I understand that I must contact the clinic.

In the event that my health insurance policy does not cover mental health services, or if my insurance plan denies payment due to lack of coverage, coordination of benefits, or any other reason that cannot be rectified within 30 days, I understand that those charges will drop to patient responsibility, and I will need to pay them. Should the insurance details I provide to Mending Mental Health later prove inaccurate, leading to claim denials, I understand that I will be responsible for any denied charges. I accept full responsibility for my treatment and release Mending Mental Health and its staff from liability should any complications arise from my treatment.

Financial Responsibility for Services Rendered

I am aware that I am financially responsible for all services provided by Mending Mental Health, irrespective of any reimbursement from my insurance provider. Should I receive reimbursement directly from my insurance company, I agree to submit those payments to Mending Mental Health immediately. I understand that this agreement is between my insurance carrier and me, not with Mending Mental Health.

I acknowledge that I have read and understand the financial policies and disclosure requirements outlined above. I agree to comply with these policies and authorize Mending Mental Health to charge my card on file as described.

Authorization of SureScripts e-Prescription Network

I understand that this authorization enables my healthcare providers to electronically send my prescription information to participating pharmacies and other providers involved in my care. This authorization is voluntary, and I understand that I make revoke it in writing at any time. My revocation will not affect actions taken before the date it was received by Mending Mental Health.