General Intake Consent
Please read the following information carefully. If you need assistance or have
questions, please speak with an administrator or your provider. There are copies of
Lakeview’s policies and procedures in the lobby .
LATE CANCELLATIONS / NO SHOWS
You must cancel your appointment no later than 24 hours prior to your scheduled time
to avoid the cancellation being marked as a late cancellation.
Lakeview Behavioral Health tracks the number of late cancellations and no shows in the
preceding 12 months. Lakeview does not charge a no-show fee. Each individual
provider can have their own policy regarding late cancellations and no shows. This may
include losing the option of having recurring appointments and/or being discharged from
the provider’s caseload. Please speak with your provider about their policy. Your care
is important to us and compliance with keeping scheduled appointments is vital to your
success. If you need to explore finding a provider that best meets your needs and
schedule please contact our office.
INDIVIDUAL PROVIDERS POLICIES
Lakeview Behavioral Health practices within Federal, State, County, contractual and
internal policies. Each individual provider is afforded discretion related to policies, that
are not otherwise required by law, and requests to complete forms. These forms may
include, but are not limited to: Family Medical Leave (FMLA) forms, emotional support
animals, medical opinion forms, county/government forms, documentation for medical
surgeries and general letters.
NOTICE OF PRIVACY AND CONFIDENTIALITY PRACTICES
for client protected healthcare information
During the course of care at Lakeview Behavioral Health, staff may gather information
about a client’s medical history and their current health. This notice explains how that
information may be used and shared with others as well as client privacy rights
regarding this kind of information. The terms of this notice apply to information created
or received by Lakeview Behavioral Health. We are required by law to make sure that
information that identifies the client is kept private; give the client notice of our legal
duties and privacy practices with respect to medical information about them; follow the
terms of the notice that is currently in effect; and notify the client in the event that there
is a breach of any unsecured protected health information about them.
Lakeview Behavioral Health seeks to strictly abide by all applicable confidentiality
regulations, including CFR 42, Chapter 1, Part 2, “Confidentiality of Substance Use
Disorder Patient Records”, and any applicable sections of Minnesota Statute Chapter
13, “Data Privacy Act” if applicable. All information requested by this facility will be used
for one or more of the following purposes:
1. To evaluate the client's need for and level of care.
2. To develop a treatment plan that is best suited to help the individual and to
provide, coordinate and manage each client’s care and treatment.
3. To fulfill county, state and federal requirements for reports and record keeping.
4. To utilize consultation services.
5. To coordinate payment. We may disclose medical information about clients so
that the treatment and services they receive may be billed to, and payment may
be collected from, the client, an insurance company, or another third party.
6. For operations of Lakeview Behavioral Health, including evaluating staff
performance and treatment and care services.
7. For sending appointment reminders and other communications to the client.
8. As required by federal, state or local law.
No other uses will be made of this information unless noted or otherwise authorized by
law.
Access will be limited to persons whose work assignments require access to
accomplish as authorized by law.
Clients have a legal right to confidentiality during and after their time of treatment here.
We honor this right by not informing anyone before, during, or after treatment of the
client’s presence here without their written consent, including inquiries in person, in
writing, or by telephone. We expect clients to honor the rights of their peers in treatment
so that all may remain anonymous. This includes not communicating in any way “client
information” to any person outside the Counseling Center without the express written
consent of the affected person.
Risks
A client entering services at Lakeview Behavioral Health may experience risks that are
beyond the control of this center and its staff. These are as follows:
1. Observation of the client’s physical presence at the facility or functions of
Lakeview Behavioral Health.
2. The possible repercussions that may arise from social stigma attached to the
diagnosis of substance use disorder or any mental health problem.
3. Disclosure of information by the client in a group setting may be viewed
negatively or judgmentally by others and result in a certain degree of emotional
pain for them.
4. The risk that an employer may react in a negative manner if they were to
discover the employee’s participation in the program or diagnosis.
5. The diagnosis of a mental health or substance use concern, as required by
insurance companies, employment applications or other legal documents may
have a detrimental effect.
Exceptions
1. We may disclose client information if the client has threatened a clear, substantial
risk of harm to self or others. Reports may be made, as required by law, to an
individual or agency that is able to help prevent the threat.
2. Clients under 18, where it is in their best interest to disclose information.
3. We may disclose information in response to a valid court order, administrative
order, certain types of subpoenas, discovery requests, if the client’s condition has
been put at issue in civil litigation, and other lawful process.
4. We may disclose information to law enforcement in the above circumstances
along with the following; to identify or locate a suspect, fugitive, material witness,
or missing persons, about a death we believe may be the result of criminal
conduct, about criminal conduct at our facility, and in emergency circumstances
in regards to a crime.
5. If unethical conduct on behalf of another provider, a report must be made to the
licensing board.
6. We may release medical information to organizations that handle organ
procurement to facilitate organ or tissue donation and transplantation. This
information will be limited to only what is necessary to make a transplant
possible.
7. We may release information to military command authorities if the client is a
member of the armed forces if we are required to do so by law or when we have
been given client consent.
8. We may release information to workers compensation or similar programs that
provide benefits for work-related injuries or illness.
9. We may disclose information to public health authorities for public health
activities. These generally include preventing or controlling disease, injury or
disability, reporting births and deaths, reporting abuse or neglect of a child or
vulnerable adult, reporting reactions to medications or problems with products,
notification of product recalls, notification on exposure to disease or condition
and reporting to the FDA.
10. We may disclose client information to health oversight agencies, for purposes
such as government audits, investigations, inspections, and licensure activities,
which are necessary for the government to monitor the health care system,
government programs, and compliance with civil rights laws.
11. We may disclose information to a coroner or medical examiner in the case of
certain types of death, and we must disclose health records upon request of the
coroner or medical examiner and funeral directors, if necessary to carry out their
duties.
12. We will release client information to authorized federal officials for intelligence,
counterintelligence, national security activities, or to provide protection to the
President, other authorized persons, or foreign heads of state or conduct special
investigations as required by law or with client’s written consent.
13. If the client is an inmate of a correctional institution or under the custody of a law
enforcement official, we will release medical information about them, as permitted
by law, to institutions or officials.
Depending on the program you are in we may need a release of information to release
some of the above, if so we will seek your consent for a release of information before
releasing any information.
Client Rights Regarding Client Information We Maintain
Lakeview Behavioral Health is required to obtain a written authorization from the client
for most uses and disclosures of notes and protected health information. Except as
described in this notice, Lakeview Behavioral Health will not use or disclose client health
information without a specific authorization from the client. A client may, at any time,
revoke an authorization that they have given. In the event that an authorization has
been revoked, it will no longer be used to disclose information, except as previously
outlined in this notice. Lakeview Behavioral Health is unable to take back disclosures
that have already been made with authorization, and is required to retain records of the
care that was provided to the client.
Clients have the right to inspect and receive a copy of their information that is used to
make decisions about their care. To request to see or receive copies of their medical
information, clients should contact Lakeview Behavioral Health administrative staff in
writing, to 516 S Pokegama Ave. Grand Rapids, MN 55744, or via phone, at (218)
327-2001. If the client’s record is maintained electronically, they may request their
record electronically. If proper written consent has been given by the client, we may
send records directly to an entity or person of their choosing.
If the client believes that their information is incorrect or incomplete, they have the right
to request that the information be changed, for as long as the information is kept by
Lakeview Behavioral Health. This request may be submitted to administrative staff at
our facility. Lakeview Behavioral Health staff may deny a client’s request for an
amendment if it does not include a reason to support the request, if the document was
not created by Lakeview Behavioral Health, is not part of our facility records, is not part
of the information which may be inspected by the client, or is the information is accurate
and complete.
Clients have a right to request an “accounting of disclosures.” This is a list of
disclosures made from our facility of client health information. This request must be
submitted in writing to Lakeview Behavioral Health administrative staff and include a
timeframe not to exceed six years prior to the date of request.
Clients have a right to request a restriction or limitation on the medical information used
or disclosed by our facility. If a client pays for a service in full, out-of-pocket, they may
request that information not be disclosed to their health plan or third party payer. We are
not required to agree to any other request. To request a restriction, a client should
contact Lakeview Behavioral Health administrative staff and inform them of what
information they want limited, if they are limiting our use, disclosure, or both, and who
the limits should be applied for.
Clients have a right to request that communication about health matters be in a certain
way or in a certain location. To make a specific request about confidential
communication, a client should contact Lakeview Behavioral Health administrative staff.
We will accommodate all reasonable requests.
Clients may request a paper copy of this notice at any time.
Lakeview Behavioral Health reserves the right to change this notice and to make the
updated notice effective to past and future dated client information. If the terms of this
notice are changed, Lakeview Behavioral Health will provide clients with a revised
notice upon client request and the revised version will be posted in our facility. If the
client feels that their privacy rights have been violated, they should contact the
Minnesota Department of Health and Human Services, at 444 Lafayette Road St. Paul,
MN 55155 Phone: (651) 431-6500, or contact our SUDs Treatment Director, Mental
Health Clinical Director, or Executive Clinical Director at (218) 327-2001.
MN STATUTE 2023
148F.165 CLIENT WELFARE
Subdivision 1. Explanation of procedures. A client has the right to have, and a
counselor has the responsibility to provide, a nontechnical explanation of the nature and
purpose of the counseling procedures to be used and the results of tests administered
to the client. The counselor shall establish procedures to be followed if the explanation
is to be provided by another individual under the direction of the counselor.
Subd. 2.Client bill of rights. The client bill of rights required by section 144.652 shall
be prominently displayed on the premises of the professional practice or provided as a
handout to each client. The document must state that consumers of alcohol and drug
counseling services have the right to: (1) expect that the provider meets the minimum
qualifications of training and experience required by state law; (2) examine public
records maintained by the Board of Behavioral Health and Therapy that contain the
credentials of the provider; (3) report complaints to the Board of Behavioral Health and
Therapy; (4) be informed of the cost of professional services before receiving the
services; (5) privacy as defined and limited by law and rule; (6) be free from being the
object of unlawful discrimination while receiving counseling services; (7) have access to
their records as provided in sections 144.92 and 148F.135, subdivision 1, except as
otherwise provided by law; (8) be free from exploitation for the benefit or advantage of
the provider; (9) terminate services at any time, except as otherwise provided by law or
court order; (10) know the intended recipients of assessment results; (11) withdraw
consent to release assessment results, unless the right is prohibited by law or court
order or was waived by prior written agreement; (12) a nontechnical description of
assessment procedures; and (13) a nontechnical explanation and interpretation of
assessment results, unless this right is prohibited by law or court order or was waived
by prior written agreement.
Subd. 3.Stereotyping. The provider shall treat the client as an individual and not
impose on the client any stereotypes of behavior, values, or roles related to human
diversity.
Subd. 4.Misuse of client relationship. The provider shall not misuse the relationship
with a client due to a relationship with another individual or entity.
Subd. 5.Exploitation of client. The provider shall not exploit the professional
relationship with a client for the provider's emotional, financial, sexual, or personal
advantage or benefit. This prohibition extends to former clients who are vulnerable or
dependent on the provider.
Subd. 6.Sexual behavior with client. A provider shall not engage in any sexual
behavior with a client including: (1) sexual contact, as defined in section 604.20,
subdivision 7; or (2) any physical, verbal, written, interactive, or electronic
communication, conduct, or act that may be reasonably interpreted to be sexually
seductive, demeaning, or harassing to the client.
Subd. 7.Sexual behavior with a former client. A provider shall not engage in any
sexual behavior as described in subdivision 6 within the two-year period following the
date of the last counseling service to a former client. This prohibition applies whether or
not the provider has formally terminated the professional relationship. This prohibition
extends indefinitely for a former client who is vulnerable or dependent on the provider.
Subd. 8.Preferences and options for treatment. A provider shall disclose to the client
the provider's preferences for choice of treatment or outcome and shall present other
options for the consideration or choice of the client.
Subd. 9.Referrals. A provider shall make a prompt and appropriate referral of the client
to another professional when requested to make a referral by the client.
253B.03 RIGHTS OF PATIENTS.
Subdivision 1. Restraints. (a) A patient has the right to be free from restraints.
Restraints shall not be applied to a patient in a treatment facility or state-operated
treatment program unless the head of the treatment facility, head of the state-operated
treatment program, a member of the medical staff, or a licensed peace officer who has
custody of the patient determines that restraints are necessary for the safety of the
patient or others.
(b) Restraints shall not be applied to patients with developmental disabilities except
as permitted under section 245.825 and rules of the commissioner of human services.
Consent must be obtained from the patient or patient's guardian except for emergency
procedures as permitted under rules of the commissioner adopted under section
245.825 .
(c) Each use of a restraint and reason for it shall be made part of the clinical record
of the patient under the signature of the head of the treatment facility.
Subd. 1a. MS 2012 [Renumbered 253D.18 ]
Subd. 2. Correspondence. A patient has the right to correspond freely without
censorship. The head of the treatment facility or head of the state-operated treatment
program may restrict correspondence if the patient's medical welfare requires this
restriction. For a patient in a state-operated treatment program, that determination may
be reviewed by the commissioner. Any limitation imposed on the exercise of a patient's
correspondence rights and the reason for it shall be made a part of the clinical record of
the patient. Any communication which is not delivered to a patient shall be immediately
returned to the sender.
Subd. 3. Visitors and phone calls. Subject to the general rules of the treatment facility
or state-operated treatment program, a patient has the right to receive visitors and make
phone calls. The head of the treatment facility or head of the state-operated treatment
program may restrict visits and phone calls on determining that the medical welfare of
the patient requires it. Any limitation imposed on the exercise of the patient's visitation
and phone call rights and the reason for it shall be made a part of the clinical record of
the patient.
Subd. 4. Special visitation; religion. A patient has the right to meet with or call a
personal physician, advanced practice registered nurse, or physician assistant; spiritual
advisor; and counsel at all reasonable times. The patient has the right to continue the
practice of religion.
Subd. 4a. Disclosure of patient's admission. Upon admission to a treatment facility or
state-operated treatment program where federal law prohibits unauthorized disclosure
of patient or resident identifying information to callers and visitors, the patient or
resident, or the legal guardian of the patient or resident, shall be given the opportunity to
authorize disclosure of the patient's or resident's presence in the facility to callers and
visitors who may seek to communicate with the patient or resident. To the extent
possible, the legal guardian of a patient or resident shall consider the opinions of the
patient or resident regarding the disclosure of the patient's or resident's presence in the
facility.
Subd. 5. Periodic assessment. A patient has the right to periodic medical assessment,
including assessment of the medical necessity of continuing care and, if the treatment
facility, state-operated treatment program, or community-based treatment program
declines to provide continuing care, the right to receive specific written reasons why
continuing care is declined at the time of the assessment. The treatment facility,
state-operated treatment program, or community-based treatment program shall assess
the physical and mental condition of every patient as frequently as necessary, but not
less often than annually. If the patient refuses to be examined, the treatment facility,
state-operated treatment program, or community-based treatment program shall
document in the patient's chart its attempts to examine the patient. If a patient is
committed as developmentally disabled for an indeterminate period of time, the
three-year judicial review must include the annual reviews for each year regarding the
patient's need for continued commitment.
Subd. 6. Consent for medical procedure. (a) A patient has the right to give prior
consent to any medical or surgical treatment, other than treatment for chemical
dependency or nonintrusive treatment for mental illness.
(b) The following procedures shall be used to obtain consent for any treatment
necessary to preserve the life or health of any committed patient:
(1) the written, informed consent of a competent adult patient for the treatment is
sufficient;
(2) if the patient is subject to guardianship which includes the provision of medical
care, the written, informed consent of the guardian for the treatment is sufficient;
(3) if the head of the treatment facility or state-operated treatment program
determines that the patient is not competent to consent to the treatment and the patient
has not been adjudicated incompetent, written, informed consent for the surgery or
medical treatment shall be obtained from the person appointed the health care power of
attorney, the patient's agent under the health care directive, or the nearest proper
relative. For this purpose, the following persons are proper relatives, in the order listed:
the patient's spouse, parent, adult child, or adult sibling. If the nearest proper relatives
cannot be located, refuse to consent to the procedure, or are unable to consent, the
head of the treatment facility or state-operated treatment program or an interested
person may petition the committing court for approval for the treatment or may petition a
court of competent jurisdiction for the appointment of a guardian. The determination that
the patient is not competent, and the reasons for the determination, shall be
documented in the patient's clinical record;
(4) consent to treatment of any minor patient shall be secured in accordance with
sections 144.341 to 144.346 . A minor 16 years of age or older may consent to
hospitalization, routine diagnostic evaluation, and emergency or short-term acute care;
and
(5) in the case of an emergency when the persons ordinarily qualified to give
consent cannot be located in sufficient time to address the emergency need, the head
of the treatment facility or state-operated treatment program may give consent.
(c) No person who consents to treatment pursuant to the provisions of this
subdivision shall be civilly or criminally liable for the performance or the manner of
performing the treatment. No person shall be liable for performing treatment without
consent if written, informed consent was given pursuant to this subdivision. This
provision shall not affect any other liability which may result from the manner in which
the treatment is performed.
Subd. 6a. MS 1990 [Renumbered subd 6c]
Subd. 6a. Consent for treatment for developmental disability. A patient with a
developmental disability, or the patient's guardian, has the right to give or withhold
consent before:
(1) the implementation of any aversive or deprivation procedure except for
emergency procedures permitted in rules of the commissioner adopted under section
245.825 ; or
(2) the administration of psychotropic medication.
Subd. 6b. Consent for mental health treatment. A competent patient admitted
voluntarily to a treatment facility or state-operated treatment program may be subjected
to intrusive mental health treatment only with the patient's written informed consent. For
purposes of this section, "intrusive mental health treatment" means electroconvulsive
therapy and neuroleptic medication and does not include treatment for a developmental
disability. An incompetent patient who has prepared a directive under subdivision 6d
regarding intrusive mental health treatment must be treated in accordance with this
section, except in cases of emergencies.
Subd. 6c. [Repealed, 1997 c 217 art 1 s 118 ]
Subd. 6d. Adult mental health treatment. (a) A competent adult patient may make a
declaration of preferences or instructions regarding intrusive mental health treatment.
These preferences or instructions may include, but are not limited to, consent to or
refusal of these treatments. A declaration of preferences or instructions may include a
health care directive under chapter 145C or a psychiatric directive.
(b) A declaration may designate a proxy to make decisions about intrusive mental
health treatment. A proxy designated to make decisions about intrusive mental health
treatments and who agrees to serve as proxy may make decisions on behalf of a
declarant consistent with any desires the declarant expresses in the declaration.
(c) A declaration is effective only if it is signed by the declarant and two witnesses.
The witnesses must include a statement that they believe the declarant understands the
nature and significance of the declaration. A declaration becomes operative when it is
delivered to the declarant's physician, advanced practice registered nurse, physician
assistant, or other mental health treatment provider. The physician, advanced practice
registered nurse, physician assistant, or provider must comply with the declaration to
the fullest extent possible, consistent with reasonable medical practice, the availability
of treatments requested, and applicable law. The physician, advanced practice
registered nurse, physician assistant, or provider shall continue to obtain the declarant's
informed consent to all intrusive mental health treatment decisions if the declarant is
capable of informed consent. A treatment provider must not require a patient to make a
declaration under this subdivision as a condition of receiving services.
(d) The physician, advanced practice registered nurse, physician assistant, or other
provider shall make the declaration a part of the declarant's medical record. If the
physician, advanced practice registered nurse, physician assistant, or other provider is
unwilling at any time to comply with the declaration, the physician, advanced practice
registered nurse, physician assistant, or provider must promptly notify the declarant and
document the notification in the declarant's medical record. The physician, advanced
practice registered nurse, physician assistant, or provider may subject the declarant to
intrusive treatment in a manner contrary to the declarant's expressed wishes, only if the
declarant is committed as a person who poses a risk of harm due to mental illness or as
a person who has a mental illness and is dangerous to the public and a court order
authorizing the treatment has been issued or an emergency has been declared under
section 253B.092, subdivision 3 .
(e) A declaration under this subdivision may be revoked in whole or in part at any
time and in any manner by the declarant if the declarant is competent at the time of
revocation. A revocation is effective when a competent declarant communicates the
revocation to the attending physician, advanced practice registered nurse, physician
assistant, or other provider. The attending physician, advanced practice registered
nurse, physician assistant, or other provider shall note the revocation as part of the
declarant's medical record.
(f) A provider who administers intrusive mental health treatment according to and in
good faith reliance upon the validity of a declaration under this subdivision is held
harmless from any liability resulting from a subsequent finding of invalidity.
(g) In addition to making a declaration under this subdivision, a competent adult
may delegate parental powers under section 524.5-211 or may nominate a guardian
under sections 524.5-101 to 524.5-502 .
Subd. 7. Treatment plan. A patient receiving services under this chapter has the right to
receive proper care and treatment, best adapted, according to contemporary
professional standards, to rendering further supervision unnecessary. The treatment
facility, state-operated treatment program, or community-based treatment program shall
devise a written treatment plan for each patient which describes in behavioral terms the
case problems, the precise goals, including the expected period of time for treatment,
and the specific measures to be employed. The development and review of treatment
plans must be conducted as required under the license or certification of the treatment
facility, state-operated treatment program, or community-based treatment program. If
there are no review requirements under the license or certification, the treatment plan
must be reviewed quarterly. The treatment plan shall be devised and reviewed with the
designated agency and with the patient. The clinical record shall reflect the treatment
plan review. If the designated agency or the patient does not participate in the planning
and review, the clinical record shall include reasons for nonparticipation and the plans
for future involvement. The commissioner shall monitor the treatment plan and review
process for state-operated treatment programs to ensure compliance with the provisions
of this subdivision.
Subd. 8 Medical records. A patient has the right to access to personal medical records.
Notwithstanding the provisions of section 144.292 , every person subject to a proceeding
or receiving services pursuant to this chapter and the patient's attorney shall have
complete access to all medical records relevant to the person's commitment. A provider
may require an attorney to provide evidence of representation of the patient or an
authorization signed by the patient.
Subd. 9. [Repealed, 1997 c 217 art 1 s 118 ]
Subd. 10. Notification. (a) All patients admitted or committed to a treatment facility or
state-operated treatment program, or temporarily confined under section 253B.045 ,
shall be notified in writing of their rights regarding hospitalization and other treatment.
(b) This notification must include:
(1) patient rights specified in this section and section 144.651 , including nursing
home discharge rights;
(2) the right to obtain treatment and services voluntarily under this chapter;
(3) the right to voluntary admission and release under section 253B.04 ;
(4) rights in case of an emergency admission under section 253B.051 , including the
right to documentation in support of an emergency hold and the right to a summary
hearing before a judge if the patient believes an emergency hold is improper;
(5) the right to request expedited review under section 62M.05 if additional days of
inpatient stay are denied;
(6) the right to continuing benefits pending appeal and to an expedited
administrative hearing under section 256.045 if the patient is a recipient of medical
assistance or MinnesotaCare; and
(7) the right to an external appeal process under section 62Q.73 , including the right
to a second opinion.
Subd. 11. Proxy. A legally authorized health care proxy, agent, or guardian may exercise
the patient's rights on the patient's behalf.
COSTS
Lakeview Behavioral Health does not discriminate against any person receiving health
services because of his/her/their inability to pay for services or because payment for
health services will be made under Federal, State or Commercial healthcare plans.
We will charge persons receiving health services at the usual and customary rate
prevailing in the area. Persons will be charged for services to the extent that payment
will be made by a third party authorized or under legal obligation to pay the charges.
Health services will be provided at a discounted charge to persons unable to pay for
care, based on a sliding fee scale. Sliding scale fees will be based on the most current
federal poverty guidelines. Persons at 300% FPG will pay a customary rate. A sliding
fee scale is in place with incremental tiering of costs. Federal poverty guidelines and
sliding fee scale for specific charges for service are available upon request.
Lakeview Behavioral Health currently accepts most major medical insurances. We
encourage you to contact your insurance company to determine your coverage and
estimated cost of care. You may call (218) 327-2001 to speak with our Registration
Department to confirm Lakeview’s Network status with your insurance.
If Lakeview Behavioral Health is Out of Network with your insurance company, we may
bill for services and receive payment if your policy includes out of network benefits. It is
important for you to contact your insurance company to determine how this may impact
your patient responsibility and financial impact.
Payment is due at the time of service based on your insurance (copay, coinsurance,
deductibles), Sliding Fee Schedule Payment, or Private Pay status.
After your insurance is processed, a statement of remaining balance due will be mailed
to the address on file. Payment is due as per statement instructions.
The most up to date private pay rates will be provided upon request.
INFORMED CONSENT FOR TELEMEDICINE SERVICES
Telemedicine/Telehealth is delivery of care through telecommunications technology,
usually two-way videoconferencing. To improve client care, telemedicine enables
healthcare providers to deliver care while the client and provider are in different
locations.
Providers may include primary care practitioners, specialists, and/or subspecialists.
Information collected during the Telehealth visit may be used for diagnosis, therapy,
treatment, follow-up and/or education and may include any of the following:
● Client Medical Records
● Medical Images
● Live, Two-Way Audio and Video
● Output Data from Medical Devices and Audio and Video Files
● Telephone
Expected Benefits:
● Improved access to medical care by enabling a Client to remain in his/her living
and/or primary care facility while the practitioner evaluates and receives
information from another site.
● More Efficient Evaluation and Management
● Obtain Specialist Expertise, Regardless of Geographic Location
Possible Risks:
As with any procedure, there are potential risks associated with the use of telemedicine.
These risks include, but may not be limited to:
● In rare cases, information transmitted may not be sufficient (e.g. poor resolution
of images) to allow for appropriate medical decision making by the practitioner
● Delays in evaluation and treatment could occur due to deficiencies or failures of
the equipment.
● In very rare instances, security protocols could fail, causing a breach of privacy of
personal medical information.
● In rare cases, a lack of access to complete medical records may result in
adverse drug interactions or allergic reactions or other judgment errors.
Client Consent to the Use of Telemedicine
1. I understand that the laws that protect privacy and the confidentiality of medical
information also apply to telemedicine, and that no information obtained in the
use of telemedicine which identifies me will be disclosed to researchers or other
entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use
of telemedicine in the course of my care at any time, without affecting my right to
future care or treatment.
3. I understand that I have the right to inspect all information obtained and recorded
in the course of a telemedicine interaction, and may receive copies of this
information for a reasonable fee.
4. I understand that a variety of alternative methods of medical care may be
available to me, and that I may choose one or more of these at any time.
5. I understand that telemedicine may involve electronic communication of my
personal medical information to other medical practitioners who may be located
in other areas, including out of state.
6. I understand that it is my duty to inform my practitioner of electronic interactions
regarding my care that I may have with other healthcare providers.
I have read and understand the information provided above regarding telemedicine. I
hereby give my informed consent for the use of telepsychiatry in my medical care. I
hereby authorize Lakeview Behavioral Health to use telepsychiatry in the course of my
diagnosis and treatment.
GRIEVANCE POLICY
In accordance with MN Statutes 245G and 245I
Staff is available to assist in the development and processing of the grievance.
The names and means of contacting the above individuals will be given to any client,
former client, or relative/guardian upon admission to Lakeview Behavioral Health or
upon written or verbal request.
Properly filing a grievance or complaint will not subject any person to prejudicial
treatment in any program operated by Lakeview Behavioral Health.
If you have a grievance and you have discussed it with the first person on this list and
are still not satisfied, you may contact the next person on the list and so on.
● Your counselor – written or verbal
○ The counselor or first person to receive the grievance will respond within 3
days acknowledging receipt of the grievance. If the grievance is not
resolved within 3 days…
● The Clinical Director of your program – written or verbal
○ Within 15 business days of receiving a grievance, Lakeview Behavioral
Health will provide the person who submitted the grievance with a written
final response. If you are not satisfied with the outcome of the grievance
you may bring the grievance to Lakeview’s CEO or designee.
● The CEO or designee.
○ If you do not receive a satisfactory response from this highest level of
authority, you may contact the appropriate entity below:
Official Publication of the State of Minnesota,
Revisor of Statutes
700 State Office Building
100 Rev. Dr. Martin Luther King Jr. Blvd
St. Paul, MN 55155
(651) 296-2868
Office of Ombudsman for Mental Health &
Developmental Disabilities
121 7th Place East
Ste 420 Metro Square Building
St Paul MN 55101
800-657-3506
Dept. of Human Services, Licensing Division
444 Lafayette Road
St. Paul MN 55155
(651) 431-6500
You may also contact the licensing board applicable to your complaint:
Board of Social Work
335 Randolph Ave, Suite 245
St. Paul, MN 55102-5502
(612) 617-2100
Board of Nursing
1210 Northland Drive, Suite
120
Mendota Heights, MN 55120
(612) 317-3000
Board of Behavioral Health
and Therapy
335 Randolph Ave, Suite 290
St. Paul, MN 55102
(651) 201-2756
Board of Marriage and Family
Therapy
335 Randolph Ave, Suite 260
St. Paul, MN 55102
(612) 617-2220
Board of Medical Practice
335 Randolph Ave, Suite 140
St. Paul, MN 55102
(612) 617-2130
Board of Psychology
335 Randolph Ave, Suite 270
St. Paul, MN 55102
(612) 617-2230
Should any client of any program administered by Lakeview Behavioral Health choose
to appear in person before the Leadership Team, they may do so by attending the next
regularly scheduled meeting of the Leadership Team. The date, time, and location of the
next scheduled meeting of the Leadership Team will be given to any client of Lakeview
Behavioral Health.
Should any client of any program administered by Lakeview Behavioral Health choose
to contact the Leadership Team they may obtain the list of members from admin or your
provider.
The grievance procedure will be available to clients upon request and posted in all
Lakeview Behavioral Health offices.
ACKNOWLEDGEMENT/VERIFICATION/AUTHORIZATION TO ACCESS DRUG
HISTORY
By signing below, I acknowledge and consent for Lakeview Behavioral Health to access
my drug history records through the current contracted electronic prescription network
and/or the State Prescription Drug Monitoring Program (PDMP). I further consent to
Third Party contact related to my prescription information.
ACKNOWLEDGEMENT/VERIFICATION/AUTHORIZATION FOR TREATMENT
By signing below, I acknowledge that I have received, understood, had explained to me
and have been informed that I may request a copy of the consents listed below:
1. The Notice of Privacy and Confidentiality Practices, which contains information
about management of my client record and private healthcare information.
2. Informed Consent for Telemedicine Services
3. The Client Bill of Rights, which includes information on cost of treatment and
rules regarding my proper treatment.m
4. The Client’s Grievance Procedure document and am aware that the staff will help
me with paperwork if needed.
I authorize Lakeview Behavioral Health to release information acquired in the course of
my examination and treatment to third parties for the purposes of obtaining payment for
services provided and permit a reproduction of this authorization to be sent in place of
the original.
I hereby direct payment of my benefits, if any, otherwise payable to me, to Lakeview
Behavioral Health for any services rendered by their facility, not to exceed the usual and
customary charges for such services, unless revoked in writing.
I understand that I am responsible to Lakeview Behavioral Health for any and all
charges not covered by my insurance plan.
I authorize Lakeview Behavioral Health’s employees and agents to treat me for
problems related to substance use and/or mental health and have been advised that my
success in this program is my responsibility.
________________________________ __________________________
Client/Parent/Guardian Signature Relationship to Client
____________________________
Date
Revised 03/20/2024
