Every client has the right to:

• Upon admission, be informed of their legal rights for their protection throughout their course of treatment. A copy of these rights will be made available.

• Be treated with courtesy and respect. PURE therapy staff is responsible for considering the patient’s individuality and family as it relates to their ethnic, social, religious, and psychological background and to provide services that will meet these needs.

• Respectfulness and privacy as it relates to their medical and personal care program. No personal health information will be made available to any organization, agency, or individual without the patient’s written consent. This right does not apply to complaint investigations and inspections by the department of health, where required by third party payment contracts, or where otherwise provided by law. For best possible patient care, a case may be discussed with a supervising provider during case consultation or supervision.

• Be informed prior to a photograph or audio/video recording being made of the patient. The patient has the right to refuse these recordings or photographs.

• Be given current information concerning their diagnosis, treatment, alternatives, risks, and prognosis in terms the patient can reasonably understand. The patient can refuse this information. When it is not advisable to give the information to the patient it may be available to the appropriate person on their behalf.

• Know by name and specialty their mental health provider responsible for their care and expect that their provider has met the minimal qualifications required by state law to practice in their specialty. Patients have the right to request and receive information about their program and service. Patients shall be fully informed of the services available and the related charges.

• Reasonable regularity and continuity of care as far as policy allows.

• Make decisions about the plan of care before and during treatment, the right to refuse treatment, to participate in experimental research, and to take medications (unless court ordered). This right includes involving a family member or other chosen representative in your treatment.

• Be free from mental, emotional and physical maltreatment and nontherapeutic chemical and physical restraints, except in emergency situations or as authorized in writing after examination by their physician for a specified and limited period of time when necessary to protect the patient from injury to themselves or others.

• A prompt and reasonable response to their questions and requests.

• Request their own medical records and approve or refuse release of medical records to any individual outside the facility.

• Voice grievances and recommend changes in policies and services and be informed of the process to voice these grievances, including the ability to report grievances to the provider’s licensing board.

• Reasonable access to any available rights protection services and advocacy services so that the patient may receive assistance in understanding, exercising, and protecting their rights.

• Providing information about past illnesses, hospitalizations, medications, and other matters related to health status, including a copy of their written advance directive if necessary.

• Being respectful to other patients, staff, and clinic property. Patient is responsible for loss or damage to clinic property.

• If the patient is responsible in any way for an injury to staff, patient assumes liability and a worker’s compensation claim may be pursued.

• Telling their providers if they expect problems in following prescribed treatment.

• Keeping appointments. A 24-hour cancellation notice is required, or a cancellation charge may be incurred.

• Attending scheduled appointments consistently as determined between patient and provider. Provider has the right to cancel further sessions if the patient is not attending consistently, with the obligation that other referral options will be provided.

• Giving necessary information for insurance claims and for working with PURE therapy to make payment arrangements, when necessary.

• Protecting their belongings. PURE therapy is not responsible for any lost or stolen items.

• Communicating any questions or concerns they have to our staff, and it is our staff’s responsibility to follow up on these questions or concerns.

*More information can be found: Minnesota Patient Bill of Rights and 245I Client Rights

MN Statute 144.651 Subd. 20 and MN Statute 245I.12 Sub 5 identify that past and current clients or their authorized representative have the right to voice grievances and recommend changes in policies and services to our staff, free from restraint, interference, coercion, discrimination, or reprisal, including threat of discharge.

Please submit your written grievance to: PURE Therapy, LLC by mail at 1409 Willow Street Suite 201 Minneapolis, MN 55403 or email at paradise@pure-therapy-mn.com. Please inform us if you would like the assistance of an advocate. If you would like to make a formal grievance to another department, below is the contact information:

▪ MN Department of Human Services, Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Phone: 651-431-6500 Fax: 651-431-7673

▪ MN Office of Ombudsman for Mental Health and Developmental Disabilities 121 7th Place East Suite 420 Metro Square Building St. Paul, Minnesota 55101 Phone: 651-757- 1800 Fax: 651-797-1950

▪ MN Department of Health, Office of Health Facilities Complaints PO Box 64975 St. Paul, MN 55164 Phone 651-201-5000

▪ MN Department of Human Rights Freeman Building 625 Robert Street N Phone: 651- 539-1100 Fax: 651-296-9042

▪ MN Department of Human Services Equal Opportunity and Access PO Box 64997 St. Paul, MN 55164 Phone: 651-431-3040 Fax: 651-431-7444

▪ MN Board of Behavioral Health 335 Randolph Avenue Suite 290 St. Paul, MN 55102 Phone: 651-201-2756 Fax: 651-797-1374 Email: bbht.board@state.mn.us

INSURANCE CODE DESCRIPTION:

90791 - Intake (DA) 60 min $285

90834 - Individual Therapy 38-45 min $200

90837 - Individual Therapy Ext. 53-60 min $225

90832 - Individual Therapy (brief) 16-37 min $175

90853 - Group Therapy 45 min $70

NOT BILLABLE TO INSURANCE:

Late Cancel/Rebook $100

No Show $175

Professional Consultation Services 60 min $200

Business Consultation Services 60 min $300

Fees, Phone Calls, Letters/Reports 1-15 min $37.50

Court Appearances 45-50 min $250

KAP Exploration Session 90-120 min $500-$800