Notice of Privacy Practices Of Apricity Counseling and Wellness LLC and Consent for Treatment

Updated December 30, 2024

This notice describes how your medical records and related personal information may be used and disclosed by Apricity Counseling and Wellness LLC (“Apricity”) and how you are able to access this information. Please review it carefully. This consent form applies to all providers and all locations that I may receive care at through Apricity.

Apricity is required by law to maintain the privacy of your protected health information (PHI). This document provides you with notice of your privacy rights and the legal duties and privacy practices of your practitioners and Apricity with respect to your PHI. All terms of this notice regarding your PHI will be followed, unless terms are amended or added, to remain in accordance with federal and state law. If this notice changes, you will receive a copy of the revised notice via U.S. mail, to the last address you have provided for this communication purpose, or via email if you have indicated you prefer to receive electronic communication. At any time, you may request a paper copy of this notice, or an amended version, and one will be provided to you.

Understanding Your Protected Health Information

Protected health information is any identifiable patient information that contains:

Any information that concerns your health and medical status or personal identifying information;
Any information about medical or psychiatric care that has been, is being, or will be delivered to you;
Financial information regarding payment for your medical visits and procedures and insurance information; and
Any information about genetic testing, results, or information about you or your family members; a request for genetic services; clinical research participation that is related to genetics; or symptoms and/or diagnosis of a genetic disease or condition of either you or your family member(s).

The purpose of creating and storing your medical record is to document your hospital and clinic visits and communications between you and your health care providers. This process allows Apricity to provide informed and quality care to our patients and to remain in compliance with all applicable federal and state laws. Your medical record will contain, among other things, examinations and test or lab results, diagnoses, treatments, visit notes, prescription orders, and a plan for future care or treatment.

Your Health Information Rights

Although your health record is the physical property of Apricity, the information contained in it belongs to you. You have the following privacy rights:

1. The right to request restrictions on the use and disclosure of your PHI to carry out treatment, payment, or health care operations.

It is important for you to know that if agreeing to certain requests would negatively affect your care, Apricity reserves the right to deny your request.

If you pay out-of-pocket, in full, for a health care or service cost, you may request Apricity to not share that information or the information related to your service with your health insurer, and Apricity will abide, provided there is not a law that requires that information to be shared.

2. The right to ask Apricity to correct health information that you believe to be incorrect or incomplete. Please ask us how to do this. Apricity reserves the right to deny your request, and you will be given notice in writing within 60 days as to why the request was denied. Additionally, if your request is denied, you can speak with your health care provider and request documentation of your request to be included in your health record, along with the denial, and for those documents to be included in any future disclosures of your PHI. Your request for amendment will automatically be denied if the documentation was created by an outside agency.

3. The right to ask us to contact you confidentially. You may specify to us the means in which you would prefer communications (via telephone, U.S. mail, email, etc.), and Apricity will do its best to accommodate this request, within reason.

4. The right to request restrictions on the use and disclosure of your name, location of where you receive treatment or care, your health or medical status, diagnoses, or any other identifying information. You have the right to limit:

disclosure to your family and friends;
certain disclosures to those involved in your care, unless it would negatively affect the quality of the care you would receive; or
in the event of a disaster relief situation.

5. The right to get a list (an “accounting”) of those with whom we’ve shared your health information and why. This information is available to you for up to six years prior to the date you request this list. Not included in this list is:

Disclosures you requested Apricity to make to specific individuals or entities.
Disclosures done for purposes of payment.
Disclosures that are industry practice for health care operations.
Disclosures that are mandatory according to federal and state law or for the purposes of maintaining our license with DHS or the Department of Health.

One accounting will be available to you per year at no cost. If you require more than one list in a 12 month span, you may be required to pay a reasonable fee for it.

6. The right to file a complaint if you feel your rights have been violated and Apricity will not retaliate against you if you file a claim.

You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by:

sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201;
calling 1-877-696-6775; or
visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

7. The right to inspect and copy your PHI, in the presence of an Apricity staff person, including all psychotherapy notes in the state of Minnesota. The only exception is if your clinician or treatment team has determined that disclosure to you of the information contained would be detrimental to your physical or mental health, or it is likely to cause you to inflict self-harm or harm to another.

You may request copies of your PHI by submitting a written request or filling out a release of information form that details your request. Apricity will provide requested documents within a reasonable period, and always within 30 calendar days of your request. There may be a fee for record retrieval or any paper copies that need to be made. This fee will not exceed the maximum allowed fee for medical record retrieval according to Minnesota law.

8. The right to rescind a release of information or authorization to release your PHI to an outside entity or agency. If the information has already been shared with your permission, we cannot take the information back, however, if you have given permission and change your mind, you can rescind the release of information at any time. You may do this by submitting your request in writing.

Apricity’s Responsibilities regarding your PHI:

It is our duty to keep your health information secure, private, and protected.
It is our duty to notify you if there has been a breach of your health information.
We will follow the responsibilities and practices laid out in this notice and remain up to date with changes in federal or state law to remain in compliance.
We will abide by your requests regarding your PHI, within reason, and according to applicable federal and state law.
We will never share your information without written consent from you for marketing purposes or sale of your information.
We will make all attempts to ensure your PHI is a thorough and complete representation of the services and treatments you receive with Apricity.

How Apricity may use or disclose your PHI, with your consent (please note that releases of information or written consent that is signed and dated is generally only valid for a period of one year, or less if specified):

For the purposes of your treatment, payment for services, and the general operations of Apricity.
When you have requested your medical record, or portions of your medical record, be released to another agency/entity.

Apricity may share your personal information with public health or other authorized agencies without your consent (under federal and state law) when:

The disclosure is to a related entity that is affiliated with Apricity and it is related to your treatment.

The disclosure is to provide health care services in the event of a medical emergency.
Legal actions require it, such as a court order, grand jury subpoena, warrant, or other legal process or for law enforcement purposes.
It is necessary to protect or reduce a serious threat to someone’s health or safety. You will be informed of this disclosure, unless informing you would further put that person’s safety or health at risk.
Suspected abuse or neglect of a child or vulnerable adult is reported.
It is a part of Apricity’s oversight activities, such as audits, inspections, or investigations from a government agency.
It is a part of managing our operations, such as with business partners that we do work with but are not our employees or affiliates. These business partners have signed a Business Associate Agreement that requires them by law to keep your information secure and protected.
It is required for workers’ compensation claims to communicate with an insurer or employer.
A state health professional licensing board requires certain information to be disclosed.
It is necessary to work with a medical examiner or coroner.
To communicate with insurance or payers for an independent medical examination.

Special Provisions for PHI Related to Behavioral Health Services or Substance Use Treatment:

Behavioral health services and records related to substance use treatment may be a part of your PHI. These portions of your health record will always require written consent that explicitly states the types of records that will be released or communication that can take place, the purpose of the release, the expiration date, and the person, agency, or entity the records are to be released to.

Additionally, in the state of Minnesota, psychotherapy notes are considered to be a part of the medical record for which clients have the right to review. This is to ensure that patients have full access to their complete health information. The only time psychotherapy notes can be withheld is if your provider determines that release of the notes, or any part of your medical record, could cause harm to you or others.

Mandated Reporting

Under certain State Law, persons in designated professional occupations are mandated to report suspected child abuse or neglect of vulnerable adults. Persons who work with children and families are in a position to help protect children and vulnerable adults from harm. These persons may be required by law to report to authorities if they know or have a reason to believe that a person is being abused or neglected, and this may be done without your consent. Behavioral health personnel may be required to break confidentiality and report certain information to the appropriate authorities.

Medical Power of Attorneys/Durable Power of Attorneys

If you have a health care directive and have appointed a medical power of attorney or a durable power of attorney, this appointed person will have the ability to make medical decisions for you and access your PHI, but only in the case that you become incapacitated or incompetent.

Adults who Have Guardians

If a guardian has been appointed to you through a court order, your guardian has the power to give necessary consent for you to receive medical or professional care and your guardian also has full access to your PHI.

Minors

Minors are persons who are under the age of 18. Parents of certain minor children, who are able to consent for treatment on their own without their parent’s involvement, do not have access to their minor child’s health record and the release of records or PHI will require written consent from the minor child. The only exception to this is if the health care professional treating the minor believes that failure to inform the minor’s parent or guardian would seriously jeopardize the health of the minor patient. Minors who are able to consent for treatment on their own include:

Minors who live apart or separately from their parents or legal guardians and is managing his or her own financial affairs.
Minors who are married.
Minors who are parents to a biological child.
When the services are to determine the presence of or to treat pregnancy and conditions associated therewith.
When the services are related to venereal disease(s)/STDs/STIs.
For Hepatitis B vaccinations.
When the services are for the assessment or treatment of alcohol or drug abuse.
Minors who are age 16 or older for nonresidential (outpatient) mental health services.
Emergency treatment for medical, dental, or other health services if the risk to the minor’s life or health is of such a nature that treatment should be given without delay and the requirement of consent would cause a delay in treatment.

Additionally, parents may be deemed to not be personal representatives of their minor child, and therefore have limited or no access to their minor child’s PHI if the minor is subject to domestic violence, abuse, neglect, or endangerment and notifying the parent of the minor’s PHI may place the minor in further danger.

Cell Phone, Cameras, or Other Recording Devices

It is our duty and responsibility to ensure that your PHI is kept secure and protected; therefore, we prohibit any type of recording or photographs while you are receiving services. Some providers may require additional protection that may necessitate you to surrender your mobile device, or any other type of recording or photography device, while you are actively receiving services. Apricity may also take action and potentially discharge you from services if confidentiality rules are not abided by in regard to photography or recording.

For information or concerns related to Privacy Practices, please contact Apricity at:

Privacy Officer Name: Sam Franklin, Mackenzie Kerber

Business Name: Apricity Counseling and Wellness

Business Address: 3464 Washington Drive, Suite 115, Eagan, MN 55122

Telephone number: 651-348-8551

Email: admin@apricitycw.com

Consent for Treatment

I acknowledge and understand that I have sought out treatment for a physical or behavioral health condition and that I consent to Apricity and its providers providing care for me. The care may include, but is not limited to: management of symptoms, diagnosis, testing, therapy, education, prescriptions, and other various types of treatment. In order to effectively provide me care, I understand that information may need to be gathered, and that this will become a part of my health record with Apricity.

I also understand that I may refuse treatment, or certain types of treatment, at any time, however, refusal may negatively affect my overall outcome of treatment. In health care, there are no guarantees for specific outcomes.

Health Records and Personal Health Information (PHI)

I acknowledge that if there is a particular request I have regarding my PHI, I will make this known to my provider or providers and that they will do their best, within reason, to honor my request.

I also acknowledge that in order for Apricity to release my records or PHI, upon my request, to another person, agency, or entity, it will require me to sign a release of information, that cannot be consented to orally.

If at any time I decide I want to revoke a release of information, I must do so in writing.

Communication

I understand that Apricity may need to contact me to discuss services I have received, financial matters related to billing, and for future appointments or services. I consent that Apricity may contact me (please check the box of which forms of communication you consent to and fill in the contact information):

Email: ________________________________________________________

Home Phone: __________________________________________________

Cell Phone: ____________________________________________________

Home Address: _________________________________________________

Other: _________________________________________________

Can staff leave a message on your phone regarding upcoming appointments?

Do you consent to text messages from Apricity?

Health Records for Research Purposes

Medical research is a fundamental way for health care and health care treatments to evolve and improve. My health records, if I consent, will always be handled according to all applicable federal and state privacy laws, and many times, my name will not be connected to the information released from my health record.

I have checked this box because I do not consent to my health records to be used for research purposes.

Consent to Communicate with Insurance

I acknowledge and understand that Apricity will need to release my PHI for purposes of billing, claims, and payment for the services I receive. I consent to all necessary communication between third parties that is related to billing, claims, or payment for services.

I also acknowledge that it is my responsibility to submit all insurance information to Apricity and to contact my insurance company to inquire about coverage for the providers I may see and the services I may receive.

Privacy Practices Notice and Client Consent Form

By signing this form, I acknowledge that I have been given an opportunity to review the Privacy Practices and Client Consent, have received a copy if I requested one, that I understand the information presented, and I agree to the provisions contained in this form. If I have questions or concerns, I will speak to my provider or an appointed person with Apricity. I understand that this form is valid until revoked by me in writing.

________________________________________________ ___________________________________

Signature of Patient/Client or Legal Representative Date

_________________________________________________

Relationship to Patient/Client (if applicable)