INFORMED CONSENT FOR PSYCHOTHERAPY
GENERAL INFORMATION
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for Sunrise Counseling Center (SCC) and each client to have a full and clear understanding of the therapeutic relationship, treatment processes, and shared expectations. This consent will provide a clear framework for best mutual understanding. Please read and indicate that this consent has been reviewed, and the information provided is agreed upon by listing a client and/or guardian or representative signature(s) at the end of this document.
CONFIDENTIALITY:
Any session content and all relevant materials and information related to the client’s treatment will be held confidential unless the client provides written permission for specific records and/or all electronic health record information for specific entities and/or person/persons.
VIDEO SURVEILLANCE NOTICE (established 08/18/2025)
In accordance with Minnesota Statutes § 144.6502, Sunrise Counseling Center employs visible video surveillance (video recording only; no audio) in common areas including the entrance, waiting room, and administrative offices for the purposes of safety and security. Surveillance recordings are securely stored, accessible only to authorized personnel, and retained for no longer than 30 days unless retained longer due to specific incidents involving physical harm, legal investigations, or training related to provider safety. Pursuant to Minnesota Statutes § 245A.11, which mandates transparency in the use of electronic monitoring devices, Sunrise Counseling Center provides this notice to all individuals to safeguard privacy during mental health treatment and ensure safety within common areas of the facility. Such surveillance complies fully with Minnesota confidentiality laws and ethical standards governing Protected Health Information (PHI) and does not violate the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
EXCEPTIONS TO CONFIDENTIALITY INCLUDE:
1. To improve treatment outcomes, the treating provider may discuss aspects of a client’s case within confidential treatment team meetings that include other clinical staff members of Sunrise Counseling Center for clinical consultation.
2. Client health insurance companies may require client records to process claims.
3. State law requires a report be made to proper authorities regarding suspected abuse of a minor children and vulnerable adults; use by a pregnant woman of a controlled substance for non-medical purposes; and sexual abuse of patients by other mental health professionals.
4. State law requires proper authorities and potential victims be notified if there is a reason to believe a client is a danger to themselves or others.
5. Adults have the right to review their records and parents have the right to review the records of their minor children, however, the therapeutic provider may request the parent limit their requests to review charts and instead accept ongoing verbal updates regarding the minor’s progress and/or notification of concerns when/if they arise. This method of communication allows the minor to feel more comfortable sharing personal information in sessions and allow the clinician to inform parents of any imminently dangerous behavior report by the minor that requires immediate action by parent(s) or guardians.
6. Parents and/or spouses may have access to deceased minors or spouse’s health records.
7. A Court may subpoena confidential records.
8. The SCC provider may share information with a Primary Care Provider or physician, to discuss specific information shared with the client when it directly affects the client's medical care.
9. Information may be shared with loved ones or healthcare providers if the client is at imminent risk from themselves, if imminent risk is a concern of the client to others, or from others to client. It is always the intention of the provider to discuss and obtain client consent prior to sharing information.
PATIENT BILL OF RIGHTS
1. To expect that a clinician has met the minimal qualifications of training and experience required by state law.
2. To examine public records maintained by the Minnesota Board of Marriage and Family Therapy, the Minnesota Board of Social Work or the Board of Behavioral Health listing the credentials of the clinician.
3. To obtain a copy of the Code of Ethics from the State of Minnesota Board of Marriage and Family Therapy, 335 Randolf Ave Suite 260, St. Paul, MN 55102; the Minnesota Board of Social Work, 335 Randolph Ave Suite 245, St Paul, MN 55102, and/or the State of Minnesota Board of Behavioral Health, 335 Randolf Ave Suite 290, St. Paul, MN 55102.
4. To report complaints to the State of Minnesota Board of Marriage and Family Therapy by calling (612) 617-2220, Hearing Speech Relay (800) 627-3529; the Minnesota State Board of Social Work at (612) 617-2100; or and/or State of Minnesota Board of Behavioral Health by calling (651) 201- 2756, Hearing Speech Relay (651) 797-1374.
5. To be informed of the cost of professional services before receiving the service.
6. To privacy as defined by the rule and law.
7. To be free from being the subject of discrimination on the basis of race, religion, gender or other unlawful categories while receiving services.
8. To be free from exploitation for the benefit or advantage of a therapist.
THERAPEUTIC PROCESS, ASSESSMENT AND SCOPE OF PRACTICE
Participation in therapy may result in many different beneficial outcomes for each client. These include but are not limited to experiencing lessening of mental health symptoms, to successful management of symptom-specific concerns that motivated each client to seek therapy. It may assist in the improvement of interpersonal communication and relationship success or increased personal insight and improve client self-efficacy in daily life. These benefits, however, rely on the individual client's effort and involvement in sessions. Psychotherapy requires each client's active participation, honesty, and openness to initiate change and/or improve their thoughts, feelings, and/or behaviors. The therapist will ask for feedback and views on the therapy sessions, its progress, and inquire about other aspects of therapy. The therapist will expect the client to respond openly and honestly. During the assessment and/or therapy, remembering or talking about unpleasant events, feelings, or thoughts may result in the client experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc. The client may also experience anxiety, depression, insomnia, etc. The therapist may challenge some client assumptions, perceptions, or propose different ways of viewing, thinking about, or handling different situations. This may cause the client to feel different emotions such as anger, depression, upset, challenged, or even disappointed. The effort put forth to resolve issues that initially brought the client to therapy, such as personal or interpersonal relationships, may result in changes that were not originally intended. Therapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships.
Sometimes a decision that is positive for one family member is or may be viewed negatively by another family member. Change is sometimes easy and swift, but more often it is slow and even frustrating. There is no guarantee that therapy will yield positive or intended results. During therapy, the therapist will likely utilize a variety of psychological approaches according, in part, to the problem that is being treated and the initial assessment of what will best assist the client. Sometimes more than one therapeutic approach may be helpful to address different situations or concerns that arise in sessions. These approaches include, but are not limited to; Solution-focused, client-centered, behavioral modification techniques, cognitive-behavioral, Rational Emotive Behavioral, Dialectical Behavioral, cognitive processing, Psychodynamic, Systemic or Family Systems Theory, Schema, Strengths-based, Transgenerational, Existential, Experiential, Trauma-Focused Cognitive Behavioral, Acceptance and Commitment, Family developmental (adult, child, family) and/or psycho-educational.
SCC does not provide custody evaluation recommendations, medication or prescription recommendations, nor legal advice as these activities do not fall within a therapist’s scope of practice. A provider/therapist may, however, assist a client to advocate for themselves in these areas to seek additional knowledge and/or resources.
DISCUSSION OF TREATMENT PLAN
After the initial treatment assessment, within a few sessions, the therapist will discuss and ask for client collaboration in creating a working treatment plan that describes the client’s working understanding of the concerns that have been presented for therapy, coinciding with a tailored treatment plan to guide sessions going forward that will identify therapeutic objectives, goals, and potential outcomes of treatment. During this time if a client has any unanswered questions about treatment procedures or would like clarification regarding the next steps of therapy, the potential risks of treatment, or questions of the therapist’s expertise to employ agreed-upon techniques, or the treatment itself, please ask. Clients have the right to ask about other treatments available to address client concerns or symptoms, and the potential risks associated, as well as to discuss thoroughly for full mutual understanding and collaboration. The client’s provider will discuss the estimated duration and frequency of sessions possible to meet treatment goals, as this is individualized and may fluctuate on a case-by-case basis. The provider will take time to answer all client questions fully.
TERMINATION
As set forth above, after the first few sessions, the therapist will assess if they are able to be a benefit to the client. In the following instances, the therapist may by ethical obligation, be required to provide the client with additional or alternative professional referral options for any of the following reasons:
1. If at any point during psychotherapy, a client’s therapist assesses that they are not effective in helping the client reach their therapeutic goals. At such time, they are obligated to discuss it with the client, and, if appropriate, to terminate treatment.
2. If a client’s therapist assesses the concerns the client brought to therapy or any presenting concerns as something they are unable to assist the client with, and cannot ethically accept clients who in their opinion, they are unable to be of beneficial service to.
3. If at any time the client wants another professional's opinion or wishes to consult with another therapist, the therapist will assist the client in finding someone qualified, and if they have client written consent, the therapist will provide the consulting professional with the essential information needed regarding a client’s therapy.
Additionally, the client has the right to terminate therapy at any time. If the client chooses to do so, the therapist will offer to provide the client with names of other qualified professionals the client may prefer.
CANCELED APPOINTMENTS/UNKEPT APPOINTMENTS
Because of the large numbers of people seeking psychological services, failed appointments are unfair to others who may be on long waiting lists. Please take responsibility for canceling any appointments the client will not be keeping as far in advance as possible. To be helpful, therapy services are most beneficial when consistent and uninterrupted. Repeatedly missed appointments and inconsistent attendance and participation may lead the therapist to discontinue treatment or make restrictions on same-day appointments.
For example, a first appointment that is not canceled with prior 24-hour notice may result in a letter reiterating the agreement to this policy from the therapist. A second canceled appointment without prior 24-hour notification to the therapist may discontinue repeated scheduling of appointments on the same day and/or at the same time consistently, opening those appointment times for others. If three appointments are canceled without enough notice, no-showed, or repeatedly rescheduled, the therapist may provide alternative provider options to seek treatment.
FEES FOR SERVICE PAYMENTS AND INSURANCE REIMBURSEMENT
SCC contracts with Mockingbird for all billing and credentialing services. SCC will assist clients with any concerns and/or questions regarding any billing issues and/or refer any questions or concerns to Mockingbird Billing for clarification. These are the fees that are billed to insurance companies and please note that they could vary. The client is encouraged to contact your insurance carrier to identify coverage and responsibility for fees.
· The fee for the initial Diagnostic Assessment (DA) is billed to insurance at a rate of $400.00.
· A therapy session of the duration from 53 to 60 minutes is billed to insurance at a rate of $300.00.
· A therapy session lasting from 38 to 52 minutes is billed to insurance at a rate of $195.00.
· A thirty-minute psychotherapy appointment is billed at $175.00 per hour.
· An hour of family therapy with the patient present is billed to insurance at a rate of $200.00.
· An hour of family therapy with the patient not present is billed to insurance at a rate of $175.00.
- A Crisis Therapy session is billed to insurance at a rate of $400/hr.
If billing concerns are affecting any client’s ability to receive the full benefits of therapy, please share the concerns with the therapist. SCC offers Sliding Fee Scale payment options for those that qualify according to Minnesota statutes 119B.12 Sliding Fee Scale revised in 2023 (see Sunrise Counseling Center Sliding Fee Scale Per MINNESOTA STATUTES 2023). A client may apply by requesting a Sliding Fee Scale income request, a Payment Plan Schedule Agreement, and/or referencing our website at www.sunrisecounselingcenter.net, and speaking with our billing company, Mockingbird Billing by email at haley@mockingbirdbilling.com.
(CLIENT SIGNATURE LINE) ____________________________________________________________________________________________________________________________________
NOTICE OF HIPAA AND PROTECTED HEALTH INFORMATION (“PHI”) PRIVACY PRACTICES
EFFECTIVE DATE OF THIS NOTICE: January 18, 2024
THIS NOTICE IDENTIFIES HOW CLIENT CONFIDENTIAL HEALTH INFORMATION MAY BE USED AND/OR DISCLOSED AND HOW TO GAIN ACCESS TO YOUR INFORMATION.
I. SUNRISE COUNSELING CENTER (SCC) RESPECTS CLIENT PRIVACY
All health information is personal and private. SCC is committed to protecting health information and recording the care and services clients receive with the utmost professionalism and confidentiality. This notice assures that SCC will provide quality care and comply with all ethical and legal requirements. This notice applies to all records created and maintained within SCC’s mental health care practice. This notice discloses the requirements SCC adheres to regarding the use and disclosure of client Protected Health Information (PHI). Additionally, this document describes a client's rights as an individual, and the degree of personalized respect and quality care SCC is ethically bound to provide. The records (documented within a client's Electronic Health Record, or “EHR”) maintained by SCC with information regarding client-protected health information (“PHI”) and treatment, will be protected by Minnesota Law in the following ways and SCC is required to:
● Make sure that any PHI that in any way can identify a client is, and will always be kept confidential.
● Provide notice of SCC’s legal obligations and privacy practices concerning PHI.
● Adhere and follow the terms of this notice as enforced by Minnesota state laws currently in effect.
● SCC may update this Notice, and any changes applying to all information (past, present, and future) within client records. The updated Notice will be available upon request.
II. HOW SCC MAY USE AND DISCLOSE CLIENT HEALTH INFORMATION:
For Treatment Payment, or Health Care Operations:
Federal privacy regulations allow healthcare entities providing direct treatment to and with a client to use or disclose the individual’s PHI without written authorization, to provide treatment, payment or healthcare operations. SCC may also disclose client-protected health information for the treatment activities of any health care provider. This too can be done without written client authorization. For example, if a clinician were to consult with another licensed health care provider about a client's condition, SCC would be permitted to use and disclose the client's personal health information, which is otherwise confidential, to assist the clinician in the diagnosis and treatment of possible client mental health condition(s).
For the Coordination of Care or Disclosures for Treatment Purposes not limited to the minimum necessary standard, therapists and other health care providers need to review and access the full record and/or all complete information to provide optimum quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, such as consultations between health care providers and/or referrals for a client, and from one health care provider to another.
ADDITIONAL NOTIFICATIONS:
VIDEO SURVEILLANCE NOTICE (established 08/18/2025)
In accordance with Minnesota Statutes § 144.6502, Sunrise Counseling Center employs visible video surveillance (video recording only; no audio) in common areas including the entrance, waiting room, and administrative offices for the purposes of safety and security. Surveillance recordings are securely stored, accessible only to authorized personnel, and retained for no longer than 30 days unless retained longer due to specific incidents involving physical harm, legal investigations, or training related to provider safety. Pursuant to Minnesota Statutes § 245A.11, which mandates transparency in the use of electronic monitoring devices, Sunrise Counseling Center provides this notice to all individuals to safeguard privacy during mental health treatment and ensure safety within common areas of the facility. Such surveillance complies fully with Minnesota confidentiality laws and ethical standards governing Protected Health Information (PHI) and does not violate the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
LAWSUITS AND DISPUTES:
If involved in a lawsuit, SCC may disclose health information in response to a court or administrative order. It may also disclose health information about a child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell the client about the request or to obtain an order protecting the information requested.
III. CERTAIN USES AND DISCLOSURES REQUIRE CLIENT AUTHORIZATION:
1. Psychotherapy Notes. SCC providers are ethically required to keep and maintain adequate records, including “psychotherapy notes” as defined in 45 CFR § 164.501, and any use or disclosure of such notes requires written Authorization unless the use or disclosure is:a. To use in treating clients.b. For SCC training or supervising use for future mental health practitioners to improve their academic and/or independent licensing abilities in group, joint, family, or individual counseling or therapy.c. To be used by SCC to defend itself in legal proceedings instituted by the client.d. For use by the Secretary of Health and Human Services to investigate a provider or SCC’s HIPAA compliance.e. Required by law and the use or disclosure is limited to the requirements of such law.f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.g. Required by a coroner who is performing duties authorized by law.h. Required to help avert a serious threat to the health and safety of others.
2. Marketing Purposes. As providers of SCC (SCC), providers, nor SCC will not use or disclose client PHI for marketing purposes.
3. Sale of PHI. As providers of Sunrise Counseling Center (SCC), providers, nor will SCC sell a client’s PHI in the regular course of business.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE CLIENT AUTHORIZATION
Subject to certain limitations in the law, SCC can use and disclose client PHI without client Authorization for the following reasons:
1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
3. For health oversight activities, including audits and investigations.
4. For judicial and administrative proceedings, including responding to a court or administrative order, although it is SCC's preference to obtain the client's Authorization before doing so.
5. For law enforcement purposes, including reporting crimes occurring on SCC premises.
6. To coroners or medical examiners, when such individuals perform duties authorized by law.
7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counterintelligence operations; or, helping to ensure the safety of those working within or housed in correctional Institutions.
9. For workers’ compensation purposes. Although SCC's preference is to obtain an Authorization from the client, it may provide the client PHI to comply with workers’ compensation laws.
10. Appointment reminders and health-related benefits or services. SCC may use and disclose client PHI to contact the client to remind the client of a scheduled appointment. SCC may also use and disclose client PHI to tell a client about treatment alternatives, or other health care services or benefits that SCC may offer.
V. CERTAIN USES AND DISCLOSURES REQUIRE CLIENTS ARE GIVEN THE OPPORTUNITY TO OBJECT
Disclosures to family, friends, or others. SCC may provide client PHI to a family member, friend, or other person that a client(s) indicate is involved in their care or the payment for a client's health care, unless the client objects in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
VI. CLIENTS HAVE THE FOLLOWING RIGHTS WITH RESPECT TO CLIENT PHI:
The Right to Request Limits on Uses and Disclosures of Client PHI. A client has the right to ask SCC not to use or disclose certain PHI for treatment, payment, or health care operations purposes. SCC is not required to agree to the client’s request and may deny the request if it is believed the use or disclosure would negatively affect a client's well-being or health care.
The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full.
A client has the right to request restrictions on disclosures of client PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that the client(s) have paid for out-of-pocket or in full.
The Right to Choose How SCC Sends PHI to Clients.
Clients have the right to ask SCC to be contacted in specific ways (for example, home or office phone) or to send mail to a different address, and SCC will agree to all reasonable requests.
The Right to See and Get Copies of Client PHI.
Other than “psychotherapy notes,” a client has the right to obtain an electronic or paper copy of the medical record(s) and other information that SCC has about the client. SCC will provide the client with a copy, or summary of their records. If a client agrees to receive a summary, it will be provided within 30 days of receiving the written request. Also, SCC may charge a reasonable, cost-based fee for providing a specific (additional) summary of records.
The Right to Get a List of the Disclosures SCC has made.
A client has the right to request a list of instances in which SCC has disclosed client PHI for purposes other than treatment, payment, or health care operations, or for which the client would have provided SCC with Authorization. SCC will respond to a client request for an accounting of disclosures within 60 days of receiving the request. The compiled list of disclosures will include disclosures made in the previous six years unless a shorter period is requested. SCC will provide the list at no charge, but if more than one request is made within the same year, SCC may charge a reasonable cost-based fee for each additional request.
The Right to Correct or Update PHI.
Suppose a client believes there is a mistake in any PHI documentation, or that a piece of important information is missing. In that case, a client has the right to request SCC to correct the existing information and/or add the missing information. SCC may deny a request but will provide written clarification of the reasons, within 60 days of receiving the client request.
The Right to Get a Paper or Electronic Copy of this Notice.
Clients have the right to receive a paper copy of this Notice, and the right to receive a copy by email. And, even if a client has agreed to receive this Notice via email, a paper copy request may also be granted simultaneously.
Sunrise Counseling Center (SCC) contracts with Mockingbird Billing Inc., (Mockingbird) for all billing and credentialing services. SCC will assist clients with any concerns and/or questions regarding billing issues or refer any concerns to Mockingbird for clarification. They are reachable through our website at www.sunrisecounselingcenter.net or by contacting their office via email at haley@mockingbirdbilling.com, call their office at (801) 872-8704.
Authorization for Release of Medical Information and Waiver:
For mental health services provided by SCC staff, I authorize any holder of medical information documentation about me to release to my insurance company, their agents and any carriers the information needed to determine benefits or payments for such services and/or a copy of this authorization to be used in place of the original, to request payment of medical insurances benefits to the party who accepts assignment. By signing below, I am waiving my rights to confidentiality regarding SCC and its billing associates (Mockingbird, SP) to communicate with my insurance company for billing purposes, and therefore allowing my insurance company permission to review my file. I additionally authorize SCC and its billing associates and any other associates that may be hired to file claims on my behalf or to provide other help for/in the operations of SCC (i.e. secretarial or other office personnel) to gain full compensation for services provided.
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FINANCIAL RESPONSIBILITY AND ACKNOWLEDGEMENT CONSENT
FEES / PAYMENT / INSURANCE RELEASE
Must provide insurance card to get a copy of, you will be billed as self-pay until insurance is provided
FEE SCHEDULE AND CONTRACT- effective January 10, 2024
* Please note that this fee schedule is subject to change without a written notice*
Diagnostic Assessment (DA) - Adult: $400/hr
Diagnostic Assessment (DA) Child/Adolescent: $400/hr
Couple/Marital Therapy Session (Cash only) $300/hr
Family Therapy Session $175+/hr
Crisis Therapy Session $300/hr
DC: Infant to 5 yrs Diagnostic Assessment: Consists of three subsequent sessions to complete and will be listed as charges as following to your insurance:
One Diagnostic Assessment Session $400/hr;
One Individual or Family session $300/hr;
Second Individual or Family Session $300/hr
Record Request Costs: if in abundance Up to $.75/page + $10 service charge (Estimated)
COURT APPEARANCE(S):
$200/hr, beginning the time entered the courtroom, and including any wait time to provide testimony or consultation summaries.
Mileage reimbursement rates for court appearances are $.70/mile, aligning with the 2025 IRS rate.
An additional charge per hour will be charged if the address of the court hearing is further than 30 miles from the address of SCC, in Virginia, MN.
PAYMENT OPTIONS:
Payment/Co-Payment is expected to be paid through the billing company: Mockingbird Billing specialists, using Simple Practice (SP) billing systems. You will receive a bill directly from them. Please make checks payable to “Sunrise Counseling Center” or “SCC”. There will be a $30 charge for returned checks with insufficient funds or non-payable. Credit cards are accepted. A therapy session is billed in time segments, lasting up to 53-55 minutes.
SCC offers clients the option to pay copays or remaining sessions balances by credit card, or by contacting Mockingbird. They will charge remaining balances for sessions to the card that has been provided, with any remaining balance not paid for by insurance. The payment will show as a charge on the client’s bank/credit card statement. Clients may request a paper copy of this document at any time from Mockingbird Billing. SCC encourages all individuals to contact their insurance carrier to identify their level of coverage and potential fees, copays, and/or deductible costs that may occur.
SCC also offers various options for payment plans if needed. If a payment plan is agreed upon, a signed consent agreement will be created as needed, a copy for the client and the billing company as requested. The client is responsible for maintaining the agreed upon balance without it increasing above that said amount.
Clients are responsible for continuing to make the agreed upon payments. Due to changes in Minnesota law, SCC will not present unpaid balances to collection agencies, nor discontinue services for unpaid balances. However, SCC and contractors reserve the right to decrease the frequency of sessions in the event that higher balances occur, to minimize accruing unpaid balances.
SLIDING SCALE FEE:
(As previously listed) If billing concerns are affecting a client’s ability to receive the full benefits of therapy, please share any concerns with the assigned therapist. Additionally, SCC maintains a Sliding Scale Fee payment plan option that can be applied for, with criteria determined by Minn Stat. 119B.12.
I acknowledge and verify understanding that:
1. I may revoke this authorization at any time. I certify full awareness and understanding that I am personally responsible for paying any/all outstanding and/or remaining balance and/or co-pays for any services or claims denied by insurance. I understand it is my legal responsibility to provide payment for any/all services provided to me, or someone under my care.
2. I have been provided a list of costs for services, and willingly authorize “The Roses LLC: dba Sunrise Counseling Center dba SCC” (SCC) to charge all my insurance providers I have given for all mental health services rendered. I understand and authorize SCC to charge my debit/credit card with any remaining copays, deductibles, and/or co-insurance on the day of/day after service(s) rendered. I understand and agree that if I accrue a high balance to Sunrise Counseling Center they may severely decrease the frequency of my scheduled appointments to manage an unpaid balance from accruing any higher, without providing my information to a collection agency.
I also understand that it is my responsibility to notify SCC of any changes in the status of my debit/credit card and provide a valid card for the continuation of services. I am aware that my insurance company may not disperse full payment for several weeks after the date of service, and that my card may be charged at that time. Should I choose to receive a receipt of payment, I will request one.
3. I understand that if I revoke this authorization, and/or accrue a high balance to SCC, I understand they may severely decrease my scheduled appointments for nonpayment, and they will mail a written notice to the address I provided.
(CLIENT SIGNATURES)
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TELECOMMUNICATIONS INFORMED CONSENT
SMS MESSAGING, PHONE, EMAIL, TELEHEALTH, SIMPLEPRACTICE PORTAL MESSENGER, ET AL
Sunrise Counseling Center (SCC) utilizes the following technology-based treatment tools for the highest treatment efficacy and client ease of communication with their treatment team. The Electronic Health Record (EHR) program, Simple Practice (SP) provides secure portal messaging, review of forms, telehealth format, and even secure phone access. It can provide email and/or text appointment reminders, telehealth session links, and secure input into a secured Electronic Health Record program.
EMAIL:
SCC uses a company-owned domain email system that provides secure email access and will have “@sunrisecounselingcenter.net” from any SCC email response. However, emails should be utilized for basic correspondence or questions between client and therapist regarding appointments, scheduling or questions that don’t require complex responses. An email will be used primarily to provide telehealth session links via Simple Practice/Google Meet. Any email content between the client and the provider should not be misconstrued to be any form of mental health treatment, crisis management or safety planning. Email communications are not effective for therapeutic processing, discussion, or exploration of thoughts and feelings comparable or replaceable to therapeutic sessions.
SIMPLE PRACTICE (SP) PORTAL MESSAGING:
SP is an encrypted web-based program EHR utilized by SCC for documentation and recording purposes. All clients will be offered access to SP messenger portal by a SP portal invitation email, in which complete documentation can be sent by the provider, upload medical documents, form requests, or communicate with the provider regarding scheduling, basic updates, or general questions that may arise. Portal messaging is not to take the place of therapeutic sessions or crisis management.
PORTAL MESSAGING WILL BE THE MAIN METHOD OF COMMUNICATION MOST USED BY THE PROVIDER.
SIMPLE PRACTICE (SP) ELECTRONIC FAXING, HIPAA, AND PHI TRANSMISSIONS:
SP utilizes RINGCENTRAL electronic faxing of scanned information and/or documentation within the client chart. Any information electronically sent, received, or exchanged with an individual or entity will be for coordinated care reasons, or client requests only, and will adhere to all HIPAA and PHI requirements set forth by related licensing boards and federal and state governments.
EMAIL/ SMS MESSAGES / VOICEMAILS:
SCC utilizes email and RINGCENTRAL SMS messaging and SP SMS reminders for appointments. SCC may contact clients by phone to reschedule an appointment, notify a client of changes, and/or ask clarifying questions. Clients have the option to receive appointment reminders by email, text, voicemail or all of the above. If clients do not want notifications or would like to revoke this consent at any time, please notify the therapist in writing. No HIPAA information will be distributed in any text message at any time by any provider. Clients are required to monitor their personal privacy levels if sharing a phone or technological device that may allow others to view messages or information. If a text, email or message is viewed by an outside party, other than the intended client, SCC is not responsible for the outside party witnessing such information.
By signing this form, the signing client or guardian agrees and acknowledges the following:
I work with Sunrise Counseling Center (SCC). I permit Sunrise Counseling Center (SCC) and the Minnesota Department of Human Services to communicate with me electronically (i.e., telehealth phone, sms and/or email communications) about my case(s).
I have been informed the telecommunication formats used will be Google Workspace and/or Simple Practice programs, and have chosen my communication preferences of email, phone and/or sms messages within my client portal.
I understand it is my responsibility to keep my phone and computer private. I accept that I am responsible for restricting access to my selected service(s).
I understand and permit my cell phone provider to use data or sms messages for notification and may charge me fees. I understand that I am responsible for any charges from my cell phone or internet service provider, but that my information will not be shared with any third party for any reason.
I understand that if Sunrise Counseling Center (SCC) is unable to reach me at my selected service(s), they may stop attempting to communicate with me through that service.
I understand that Sunrise Counseling Center (SCC) will require phone calls and in-person visits. I understand and permit Sunrise Counseling Center (SCC) to call me.
I understand that if I change my contact information, or if my selected service is stopped, it is my responsibility to inform Sunrise Counseling Center (SCC) and provide the new, correct information.
I understand that encrypted messaging, phone calls and/or email communications sent and/or received will be imputed by Sunrise Counseling Center (SCC) as part of my permanent case record. I understand that any sms messages may also be added to my records if utilized at any time.
My consent today applies to all of my cases with Sunrise Counseling Center (SCC). It will continue until I stop this consent in writing to Sunrise Counseling Center (SCC). Sunrise Counseling Center (SCC) reserves the right to stop sending/receiving communications via email and/or sms messaging at any time.
I acknowledge that by using email and/or sms messages there may be various technicians or administrators who maintain these services. The technicians may see the content of email and/or sms messages.
I understand that if I use my work email to communicate with Sunrise Counseling Center (SCC), my employer may access those email communications.
I understand there are risks in using email and/or sms messaging to communicate with Sunrise Counseling Center (SCC). These risks may include but are not limited to, confidential information being seen or overheard by others. While Sunrise Counseling Center (SCC) will not list HIPPA information, but may reference appointments and/or scheduling, travel conditions or alternative changes in format of session (i.e., in-person or telehealth) though make every effort to keep information secure.
Sunrise Counseling Center (SCC) cannot guarantee that electronic communication is 100% safe and protected. Should I choose to email and/or sms message Sunrise Counseling Center (SCC), I agree that I am entering into electronic communication with full knowledge of the risks therein.
I understand that if I fail to maintain the security of and/or restrict access to my selected service(s), and information is seen by others, Sunrise Counseling Center (SCC) is not in violation of the Health Insurance Portability and Accountability Act (HIPAA), the Minnesota Data Practices Act (Minnesota Statutes Chapter 13), and/or the St. Louis County Data Practices Policy.
If I fail to maintain the security of and/or restrict access to my selected service(s), and information is seen by others, I hereby release Sunrise Counseling Center from all liability. I acknowledge that I may not sue Sunrise Counseling Center.
I acknowledge that SCC employees are not available after business hours or when employees are out of the office.
I may leave a confidential voicemail message for a Sunrise Counseling Center (SCC) employee after business hours, but it will not be returned until the employee has returned to the office during business hours.
For emergency assistance after hours, the on-call crisis response or emergency response can be reached at 911, or by contacting the Virginia Police, non-emergency phone number at (218) 748-7510, by stating I am experiencing hardship and would like supportive resources.
This authorization ends one year from now unless I identify an alternative date in writing with my attached signature of approval, noting an alternative date.
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19B.12 SLIDING FEE SCALE per Minnesota State Statutes 2023
Sunrise Counseling Center follows the statutes as follows:
Subdivision 1. Fee schedule. All changes to parent fees must be implemented on the first Monday of the service period following the effective date of the change.
THE PARENT FEE SCHEDULE** The parent fee schedule is as follows, Except as noted in 119B.12 Subdivision 2:
Definitions:
INCOME RANGE: PERCENTAGE OF THE STATE MEDIAN INCOME, EXCEPT AT THE START OF THE FIRST TIER
CO-PAYMENT: PERCENTAGE OF ADJUSTED GROSS INCOME.
PARENT FEE SCHEDULE:
(INCOME RANGE)———————————————CO-PAYMENT)
0-74.99% of federal poverty guidelines —————— $0/biweekly
75.00-99.99% of federal poverty guidelines ———-— $2/biweekly
100.00% of federal poverty guidelines - 27.72% ————— 2.6%
27.73-29.04% —————————————————-—— 2.61%
29.05-30.36% —————————————————-—— 2.61%
30.37-31.68% —————————————————-—— 2.61%
31.69-33.00% —————————————————-—— 2.91%
33.01-34.32% —————————————————-—— 2.91%
34.33-35.65% —————————————————-—— 2.91%
35.66-36.96%—————————————————-—— 2.91%
36.97-38.29% —————————————————-—— 3.21%
38.30-39.61% —————————————————-—— 3.21%
39.62-40.93% —————————————————-—— 3.21%
40.94-42.25% —————————————————-—— 3.84%
42.26-43.57% —————————————————-—— 3.84%
43.58-44.89% —————————————————-—— 4.46%
44.90-46.21% —————————————————-—— 4.76%
46.22-47.53% —————————————————-—— 5.05%
47.54-48.85% —————————————————-—— 5.65%
48.86-50.17% —————————————————-—— 5.95%
50.18-51.49% —————————————————-—— 6.24%
51.50-52.81% —————————————————-—— 6.84%
52.82-54.13% —————————————————-—— 7.58%
54.14-55.45% —————————————————-—— 8.33%
55.46-56.77% —————————————————-—— 9.20%
56.78-58.09% —————————————————-—— 10.07%
58.10-59.41% —————————————————-—— 10.94%
59.42-60.73% —————————————————-—— 11.55%
60.74-62.06% —————————————————-—— 12.16%
62.07-63.38% —————————————————-—— 12.77%
63.39-64.70% —————————————————-—— 13.38%
64.71-67.00% —————————————————-—— 14.00%
Greater than 67.00% —————————————-—— Ineligible
A family's biweekly co-payment fee is the fixed percentage established for the income range multiplied by the highest possible income within that income range.
Subd. 2. Parent fee. A family must be assessed a parent fee for each service period. A family's parent fee must be a fixed percentage of its annual gross income.
Parent fees must apply to families eligible for child care assistance under sections 119B.03 and 119B.05. Income must be as defined in section 119B.011, subdivision 15. The fixed percentage is based on the relationship of the family's annual gross income to 100 percent of the annual state median income. Parent fees must begin at 75 percent of the poverty level. The minimum parent fees for families between 75 percent and 100 percent of the poverty level must be $2 per biweekly period.
Parent fees must be provided for graduated movement to full payment. At the initial application, the parent fee is established for the family's 12-month eligibility period. At redetermination, if the family remains eligible, the parent fee is recalculated and is established for the next 12-month eligibility period.
A parent fee shall not increase during the 12-month eligibility period. Payment of part or all of a family's parent fee directly to the family's child care provider on behalf of the family by a source other than the family shall not affect the family's eligibility for child care assistance, and the amount paid shall be excluded from the family's income.
Childcare providers who accept third-party payments must maintain family-specific documentation of payment source, amount, and time period covered by the payment.
History: 1Sp1985 c 14 art 9 s 72; 1988 c 689 art 2 s 229; 1997 c 162 art 4 s 37; 1999 c 205 art 1 s 33; art 5 s 21; 1Sp2003 c 14 art 9 s 20; 2004 c 288 art 4 s 15; 2006 c 191 s 1; 2007 c 147 art 2 s 9; 2008 c 361 art 3 s 4; 2009 c 175 art 1 s 4; 2012 c 216 art 7 s 2,3; 1Sp2017 c 6 art 7 s 20 *
Official Publication of the State of Minnesota Revisor of Statutes MN Revisor Statute 119B.12