Adult Registration

I authorize Northland Counseling Center, Inc. (NCC) to release information to my insurance company regarding my treatment here. This could include my social security number, diagnosis, prognosis, dates of treatment, narrative notes and types of treatment and permit a facsimile or photographic reproduction of this authorization in place of the original. This is for the purpose of validating claims submitted to YOUR INSURANCE COMPANY, I also authorize to make payments to NCC for all insurance benefits to which I or my dependents are entitled for services received at NCC. I understand that my consent terminates one year from the date of signature, unless I choose to revoke it earlier.

I affirm that the information reported above is accurate and that the fee, payment method and release of information have been discussed. If my financial status changes, an update of this agreement may be renegotiated.

A health record location service helps my mental health providers determine where I have received care and obtain information about my health to help treat me. NCC may access my information in a record locator service to help provide care to me. NCC may share my health record and information with a record locator services unless I indicate NO in the box below. If I indicate NO the box below, I understand NCC will exclude my information in any record locator service.

Each month I will pay a minimum of 25% of the total balance due until all charges are paid and/or;

Following each visit, I will pay the charges for that visit and/or;

Upon receipt of a monthly statement, I will remit the amount due and/or;

I will be responsible for payment for any services denied by my insurance company, including but not limited to deductibles, co-pays and exclusions.

I understand that I am responsible for the charges in full, forfeiting my opportunity to be placed on the sliding fee scale, if I do not comply with the following (when applicable):

a. Provide verification of income documentation
b. Obtaining a physician referral when my insurance requires one.
c. Applying for medical assistance and notifying Northland Counseling Center, Inc. (NCC) of disposition if referred.
d. A fee may be charged for any missed appointments which are not canceled at least 24 hours in advance.

I recognize that it is my responsibility to be aware of my insurance benefits and payment by insurance is not guaranteed.

In the event NCC has been unable to collect payment from me for services within a reasonable period of time, NCC then reserves the right to turn the account over to an attorney or collection agency. I understand that interest, finance charges and other costs as allowed by law, will be added to my account. A 15% processing fee will be added to any account sent to collections.

PURPOSE: The purpose of this form is to inform you of the availability of telemedicine services offered by Northland Counseling Center, Inc. Telemedicine involves the use of electronic communications to enable office visits from a site other than Northland Counseling Center, Inc.

‘Telemedicine’ means using electronic systems to allow communication between a client and a provider who are in different locations. Any service that Northland Counseling Center, Inc. offers may be provided via telemedicine.

CONFIDENTIALITY: Northland Counseling Center, Inc. utilizes Zoom, a third-party web-based video-conferencing vendor, to facilitate telemedicine services. Protected health information (PHI) will be transmitted via Zoom during telemedicine visits. Zoom incorporates networking software security protocols to protect the confidentiality of patient identification and will include measures to safeguard PHI and ensure the integrity against intentional or unintentional corruption.

Reasonable and appropriate efforts have been made to illuminate any confidentiality risks associated with the telemedicine consultation and all existing confidentiality protections under Federal and Minnesota State Law applied information disclosed while utilizing telemedicine services.

RIGHTS: As a part of the admission process, Northland Counseling Center, Inc. staff will request your consent to participate in telemedicine services in connection with services provided by Northland Counseling Center, Inc. and all satellite offices associated within.

You may withhold or withdraw consent to telemedicine services at any time without affecting your right to future services with Northland Counseling Center, Inc. or risk the loss or withdrawal of any program benefits to which you would otherwise be entitled. Your request to withdraw consent must be made in writing and submitted to Northland Counseling Center, Inc. staff.

RISKS, CONSEQUENCES and BENEFITS: In rare cases, the information transmitted may be inadequate quality or, if the equipment is not working, there could be delays in evaluation and treatment. In these cases, the visit maybe rescheduled or your provider will discuss face-to-face visit needs. You or your provider may discontinue the telehealth visit if the connections are not adequate for the situation. Very rarely, security protocols could fail, causing a breach of confidentiality. Northland Counseling Center, Inc. has implemented appropriate security measures to mitigate against this rare situation.