Privacy and Forms
At MN Therapies, protecting the confidentiality of our clients is a high priority. We invite you to view the various forms below which contain information on your rights, our policies and other important information you should know. When you schedule an appointment, it is recommended you take a few moments to print and complete the forms below.
General Intake packet
(includes general information about you, your rights and the services at MN Therapies)
Health Insurance Form
(for those that would like to use insurance, please complete the top section of this form)
Release of Information
(if you are currently working with another provider regarding mental health services or treatment, please complete this form)
HIPPA
(Health Insurance Information and Portability Act 0f 1996)
****PLEASE READ THE FOLLOWING, PRINT A COPY FOR YOUR RECORDS AND SIGN THE FORM AT THE BOTTOM OF THIS PAGE****
At MN Therapies, your health information is considered confidential. There are only a few scenarios in which your information may be disclosed without your permission. These scenarios are discussed in the newest version of the Notice of Privacy Practices, effective September 23rd, 2013. You may ask for a copy of these privacy practices at any time. A link to the government issued notice, as well as the adapted MN Therapies form is also provided for you below. I encourage you to ask me any questions that you may have about your rights and my responsibilities regarding the security and privacy of your health information.
http://www.hhs.gov/ocr/privacy/hipaa/npp_layered_hc_provider.pdf
Please note that this brochure is the standard-issue notice of privacy practices. MN Therapies differs in some ways:
I will never sell your health information.
I do not currently use electronic medical records (however, a copy of your written records are available upon your request).
I will not list your information in a hospital directory.
I will never use your personal information in marketing materials.
I will ask for your written permission to discuss identifiable information with other health professionals (except in the case of an emergency where I am concerned about your safety or the safety of others).
I will not use any identifying information (names, addresses, phone numbers, or any other information that might make your identity easily known) for research purposes.
This practice is not involved in the procurement or donation of organs or tissue.