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Welcome to Covered Bridge Family Resources, LLC.  We are looking forward to meeting with you and to determining how we can be of assistance to you.  Please take the time to read the following information and ask any questions you may have regarding this information. You will need to sign a form indicating receipt of this information and giving consent for treatment.

 How Your Health Information May be Used or Disclosed
Covered Bridge Family Resources, LLC uses health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive.  Your health information is contained in a medical record that is the physical property of Covered Bridge Family Resources, LLC and/or its’ contracted therapist.

Information submitted in writing may be hand delivered to your therapist or mailed to Covered Bridge Family Resources, LLC PO Box 134 Zumbrota MN 55992.

 For Treatment.  Covered Bridge Family Resources, LLC and/or its’ contracted therapists and/or staff may use your health information to provide you with medical treatment or services.  For example, information obtained by a health care provider, such as a physician, nurse, psychologist, clinical social worker, counselor or other person providing health services to you, will record information in your record that is related to your treatment.  This information is necessary for health care providers to determine what treatment you should receive.  Health care providers will also record actions taken by them in the course of your treatment and note how you respond to the actions.  The following agency staff may use medical records: clinical staff, supervisors, receptionists, administrative assistance, transcriptionist, and medical records personnel.

 For Payment.  Covered Bridge Family Resources, LLC and/or its’ contracted therapists and/or staff may use and disclose your mental health information to others for purposes of receiving payment for treatment and services that you receive.  For example, a bill may be sent to you or a third-party payer, such as an insurance company or health plan.  The information on the bill may contain information that identifies you, your diagnosis, and treatment or supplies used in the course of treatment.  If you are eligible to receive county or grant based funding, some information about you will be provided to those staff.  The Minnesota Department of Human Services also has the right to review your medical record.

 For Health Care Operations.  Covered Bridge Family Resources, LLC and/or its’ contracted therapists and/or staff may use and disclose mental health information about you for operational purposes.  For example, your health information may be disclosed to members of the medical staff, risk or quality improvement personnel, and others to:Evaluate staff performance;Assess the quality of care and outcomes in your case;Learn how to improve our facility and services; Determine how to continue to improve the quality and effectiveness of the health care we provide; Train staff/students; andConduct interagency consultation aimed at providing quality care.

 Appointments.  Covered Bridge Family Resources, LLC and/or its’ contracted therapists and/or staff may use your information to provide appointment reminders, information about treatment alternatives or other health-related benefits and services that may be of interest to the individual.

 How Contacts are Made:  Information is exchanged with you or others designated individual/agencies in the following ways: telephone, cell phone, mail, fax, email.  Messages will be left on voicemail attached to the phone number provided.  If you do not wish to have any of these forms of communication used, you must provide us with a written notice.  If you would like confidential communication in an alternative way or at an alternative location, such as communication only at a specific phone number, or by mail only, you must provide us with that information in writing.

 Treatment Information:  Covered Bridge Family Resources, LLC and/or its’ contracted therapists and/or staff may use your information to contact you about treatment alternatives, health related benefits and services that may be of interest to you.

 Required by Law.  Covered Bridge Family Resources, LLC and/or its’ contracted therapists and/or staff may use and disclose information about you as required by law.  For example, Covered Bridge Family Resources, LLC and/or its’ contracted therapists and/or staff may disclose information for the following purposes:For judicial and administrative proceedings pursuant to legal authority;To report information related to victims of abuse and/or neglect; To assist law enforcement official in there law enforcement duties; To comply with a court order or subpoena;To report a crime at our facility.

 Public Health.  Your health information may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability, or for other health oversight activities, including disaster relief efforts.

 Safety:  Covered Bridge Family Resources, LLC and/or its’ contracted therapists and/or staff may use your information to inform necessary individuals or agencies to lessen a serious or imminent threat to the health or safety of another person or the public, including information regarding admitted participation in a violent crime or escape from lawful custody.  In addition, we may do the same if we believe there to be serious or imminent threat to your own safety by means of self-harm.

 Decedents.  Health information may be disclosed to funeral directors or coroners to enable them to carry out their lawful duties.

 Research.  Covered Bridge Family Resources, LLC and/or its’ contracted therapists and/or staff may use your health information for research purposes after an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved the research.  We occasionally develop statistics and other anonymous information about the clients we serve that will not identify you in any way.

 Health and Safety.  Your health information may be disclosed to avert a serious thereat to the health or safety of you or any other person pursuant to applicable law.

 Government Functions.  Specialized government functions such as protection of public officials or reporting to various branches of the armed services may require use or disclosure of you health information.

 Workers Compensation.  Your health information may be used or disclosed in order to comply with laws and regulations related to Worker’s Compensation.

 Your Health Information Rights
You have the right to:Request a restriction on certain uses and disclosures of your information as provided by 45 CFR  164.522; however, Covered Bridge Family Resources, LLC and/or its’ contracted therapists and/or staff is not required to agree to a requested restriction.  Requests need to be done in writing.Refuse to give any information at any time.  However, lack of information may affect our ability to help you.  You may also become ineligible for financial assistance or to receive services.Inspect and/or obtain a copy of your health record as provided by 45 CFR 164.524.  To do so, you must talk with your health care provider.  Access to your rerecords is free of charge, but you may be charged for any copies.  You may be asked to review your file in the presence of a staff person.  Records obtained from outside sources will not be released to you.  Requests need to in writing and will be responded to within 30 days.  We may deny your request for the following reasons: 1) the information is contained in psychotherapy notes 2) the information is compiled in anticipation of, or use in, a civil, criminal or administrative action or proceeding and 3) if the information is likely to be detrimental to the patient or to endanger the patient or another person. Have a denial to access your records reviewed.  The request needs to be in writing and will be conducted by a licensed mental health professional designated by us, who was not involved in the denial.  We will then comply with the outcome of that review.  Amend you health record as provided in 45 CFR 164.526.  The request must be submitted in writing, including the amendment wanted and a supporting reason for it.  We have the right to deny this request, in such a case you will informed of the reason.  All information pertaining to a request will, subsequently, become a part of the record.    Request communications of your health information by alternative means or at alternative locations.Ask us to release information to any person or organization that you choose, if you have given us your consent in writing.Revoke your authorization to use or disclose health information except to the extent that action has already been taken; andReceive an accounting of disclosures made of your health information as provided by 45 CFR 164.528.To know the cost of services.To be informed of the names, professional status and roles of the individuals involved in providing services to you.To transfer to another therapist after services have begun and/or to refuse services.To be made aware that there are risks and benefits to services and change and to discuss those with your therapist.

You may complain to Covered Bridge Family Resources, LLC and to the Department of Health and Human Services, if you believe your privacy rights have been violated.  You will not be retaliated against for filing a complaint.  If you are dissatisfied with our services, tell your therapist.  If you remain dissatisfied or still have questions, you may follow the Grievance Procedure outlined below.

 Grievance ProcedureChoose to have a staff member, family member or friend assist you through the grievance procedure.Contact the Covered Bridge Family Resources, LLC Clinical Director.If you still have concerns, put them in writing, including the date and your signature.  Send that to the Clinical Director, Covered Bridge Family Resources, LLC, PO Box 134, Zumbrota, MN 55992.  You will have a response within 5 working days.If your concerns remain, you may contact the Minnesota Board of Social Work, 2829 University Ave. SE #340 Minneapolis, MN 55414 612-617-2100 or the Board of Psychology, 2700 University Avenue West, Room 101, St. Paul, MN 55114-1095.Treatment of Minors

There are specific laws that address confidentially for minors (those under 18).  By law, custodial parents/legal guardians have the right to access mental health records except when the minor is married, legally emancipated, or has borne a child.  Other exceptions include when the information pertains to venereal disease, chemical dependency or pregnancy and related conditions.  In addition, a minor may request, in writing, including the reason, that their mental health record be withheld from their parent or legal guardian.  In addition, a therapist can withhold records if, in their professional judgment, they determine that disclosing the information would be detrimental to the physical or mental health of the minor or that the minor is likely to cause harm to themselves or another.   

 It is our goal to both maintain the privacy of our minor clients as well as keep parents/guardians informed of important information and progress.  We ask that you assist us in this by talking openly with us regarding any questions or concerns you have and allowing your child the space and privacy to develop a trusting relationship with their therapist so they can have an opportunity for growth in therapy.

 Couple/Family Therapy
In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. Your therapist will use clinical judgment when revealing such information.  Your therapist will not release records to any outside party unless so authorized to do so by all adult family members who were part of the treatment.Dual relationships

Not all dual relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs a therapists objectivity, clinical judgment, or therapeutic effectiveness or can be exploitative in nature. Therapists will assess carefully before entering into nonsexual and nonexploitative dual relationships with clients. Zumbrota and the surrounding area is a small community and many clients know each other and the therapists and employees of Covered Bridge Family Resources, LLC from the community. Consequently, you may bump into someone you know in the waiting room or into individuals from Covered Bridge Family Resources, LLC out in the community. Individuals from this agency will never acknowledge working therapeutically with anyone without his/her written permission.  Many clients choose their therapist because they know him/her before they enter into therapy with him/her and/or are aware of his/her stance on a topic.  Nevertheless, your therapist will discuss with you, the often-existing complexities, potential benefits, and difficulties that may be involved in such relationships.  Dual or multiple relationships can enhance therapeutic effectiveness but can also detract from it and often it is impossible to know that ahead of time.  It is your, the client’s, responsibility to communicate to your therapist if the dual relationship becomes uncomfortable for you in any way. Your therapist will always listen carefully and respond accordingly to your feedback.  Your therapist will discontinue the dual relationship if s/he finds it interfering with the effectiveness of the therapeutic process or the welfare of the client and, of course, you can do the same at any time.

 Litigation Limitation
Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters that may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc.), neither you (client or minor client’s parent/guardian) nor your attorney, nor anyone else acting on your behalf will call on anyone, including your therapist, from this agency to testify in court or at any other proceeding, nor will a disclosure of your records be requested.  This is requested in order to best maintain the therapeutic relationship for the client and therapist and prevent or limit possible harm that can come from exposure of personal information to those outside of the therapeutic relationship.  There may incidents when information must be released due to mandatory legal obligations beyond the scope of this agreement.

 Health Insurance and Confidentiality of Records
Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. Only the minimum necessary information will be communicated to the carrier. Covered Bridge Family Therapy Resource, LLC or our contracted billing agent, have no control or knowledge over what insurance companies do with the information submitted or who has access to this information once submitted. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or to future eligibility to obtain health or life insurance. The risk stems from the fact that mental health information is entered into insurance companies’ computers and becomes a part of your medical record there.  Confidentiality of e-mail, cell phone, and fax communication

You should be aware that e-mail and cell phone (also cordless phones) communication can be accessed by unauthorized people and, hence, the privacy and confidentiality of such communication can be compromised.    Faxes can be sent erroneously to the wrong address.  Please notify your therapist at the beginning of treatment if you decide to limit in any way the use of any or all of the above-mentioned communication devices.  However, it is important to note that such limits may delay the ability of your therapist to respond to you or your requests to exchange information.  Please use only phone contact in emergency situations when you are attempting to contact us, do not use e-mail or faxes.

 Obligations of Covered Bridge Family Resources, LLCMaintain the privacy and confidentiality of protected health information;Obtain your written authorization to use or disclose your health information for reasons other than those listed above and permitted under law;

Limits to confidentiality include:

1.      The therapist is a mandated reporter and must, by law, report any reports or suspicions of abuse or neglect to children or vulnerable adults.
2.      If the client indicates intent to harm himself or herself or another person.
3.      During the therapists’ consultation/supervision, sharing of facts will occur, in order to plan for the best possible care.  When this occurs within the agency, confidentiality does not apply, however, consultation outside of the agency will be done in a manner that does not exchange identifying information. 
4.      Subpoenas or other legal circumstances.
5.      Other applicable limits will be discussed on a case-by-case basis.Provide you with this notice of its legal duties and privacy practices with respect to your health information;Abide by the terms of this notice;Notify you if we are unable to agree to a requested restriction on how your information is used or disclosed;Accommodate reasonable requests you may make to communicate health information by alternative means or at alternative locations;Comply with the Civil Rights Policy and Standards of the Minnesota Department of Human Service.  Qualified persons will not be excluded from participation in, be denied the benefits of, nor be subject to discrimination in any manner on the basis of age, race, religion, color, sex, national origin or ancestry, sexual orientation, or marital status.  This policy covers admission policies and procedures, access to services, and treatment in all programs and activities. Offer services that are free from sexual harassment, sexual contact, and any form of exploitation.  Clinical staff is not allowed to engage in social, personal, or business relationships while providing services to you.

Covered Bridge Family Resources, LLC reserves the right to change its information practices and to make the new provisions effective for all protected health information it maintains.  Revised notices will be made available to you.  The practices became effective April 15, 2003. Your Responsibilities

As a client of Covered Bridge Family Resources, LLC, you have responsibilities as well as, rights.  You are responsible for being clear and complete about the problems you are experiencing.  It is important that you provide complete and accurate information about past and present illnesses, hospitalizations, medications, and other matters relating to your background and current life circumstances.You are responsible for assisting in the development of your treatment plan, your willingness to follow this plan, bears directly on the success of your treatment.You are responsible for keeping scheduled appointment.  If you cannot keep your appointment, please call and cancel 24 hours in advance.  Charges for appointments not cancelled are not covered by insurance companies.  You are responsible for respecting the right of privacy and confidentiality of other clients you see at our offices.You are responsible for arranging payment of the cost of service you receive and making payments at the time of service.You share responsibility with us for helping to evaluate our services.  This may involve completing a survey.  Your privacy will be respected.You share the responsibility with us in assuring that the helping relationship remains respectful and that our staff, as well as other clients and visitors, feel safe and protected.  We reserve the right to terminate contact with clients who engage in abusive language or behavior, any form of harassment, or who are perceived to under the influence of alcohol or other drugs. You have the right to terminate therapy at any time.

 Staff Rights
The Staff at Covered Bridge Family Resources, LLC are committed to respecting your rights.  The staff also has rights.

 Staff has the right to keep their private lives separate from their professional lives and do not routinely give out their home address or phone number; family information; or other personal information.Staff has the right to consult with other agency or contracted staff as needed.Staff has the right to transfer clients to other professionals or terminate therapy if they believe:

-      Their objectivity has been impaired.
-      The problems presented are outside their area of competence.
-      Therapy is not indicated.
-      The client is not benefiting from or following the treatment plan.
-      A client is being abusive.
-      The relationship would result in a conflict of interest.

Voice mail is available 24 hours a day, 7 days a week.  Messages are checked on a daily basis, unless otherwise specified.  If your message is urgent, please indicate that and leave a number where you can be reached.  If this is an emergency and you cannot wait for a returned call, please call the Crisis Receiving Unit at 1-800-422-0670, an Emergency room near you or, 911 or consult your individual crisis plan created during therapy.   Appointments are made on an individual basis.

The length and frequency of therapy appointments will be determined according to your needs.
A 24-hour notice is requested if you need to cancel.