Privacy Policy, Client Rights and Responsibilities
Your privacy regarding medical information is of utmost importance to us, and we are dedicated to safeguarding it. A comprehensive record of your care will be established for the services provided during your time as a client at our clinic. This record is essential for delivering quality care and ensuring compliance with regulatory standards. Your medical information may be disclosed to other treating providers at your request, your insurance company to facilitate payment of your claim, and to pharmacies to assist in obtaining your medications. Our complete privacy policy is prominently displayed on the waiting room wall for your reference. Additionally, you are receiving a copy of your rights and responsibilities for your records. By signing this form, I acknowledge that I have read and understood this policy and have been informed of the privacy practices implemented at this clinic.
Complaints, Grievances, or Alleged Rights Violations
I have received a copy of the procedure for reporting a complaint or grievance, and I understand its contents. I acknowledge that I have the right to file a complaint with the clinic regarding our privacy practices and compliance with applicable statutes or laws. To file a complaint, you may contact:
Office of Ombudsman for Mental Health and Developmental Disabilities
332 Minnesota St., Ste. W1410
First National Bank Building
St. Paul, MN 55101
(651) 757-1800
Ombudsman.MHDD@state.mn.us
Minnesota Department of Health
Office of Health Facility Complaints
(651) 201-4200
Health.FPC-Web@state.mn.us
Minnesota Department of Human Services
540 Cedar St.
St. Paul, MN 55101
(651) 431-2000
Health.FPC-Web@state.mn.us
Services
I authorize CPW to evaluate, administer diagnostic testing, prescribe medications, develop a treatment plan, and provide treatment with my active participation. I understand that the practice of medicine and psychotherapy involves inherent uncertainties and is not an exact science. Furthermore, I acknowledge that no guarantees have been made to me regarding the outcomes of assessment or treatment at the clinic.
After Hours Emergencies
In the event of an after-hours emergency, I understand that I can contact the clinic and follow the instructions provided on the recording. Additionally, I am aware that there are resources available for crisis assistance that I can refer to if needed.
Telephone
If CPW staff need to contact you for purposes such as appointment cancellations, reminders, or to exchange other information, we will make every effort to maintain confidentiality. By default, we will call your primary contact number and request to speak with you without disclosing our identity. If needed, we will identify ourselves as your therapist or provider's representative, but we will not reveal
our name or specify the nature of the call unless instructed otherwise. Please provide any additional instructions you would like us to follow.
Contact Preference
