Call Us:  (612) 799-6263

Health Insurance Portability and Accountably Act (HIPAA) Information:


Our professional staff is highly skilled in caring for adults, adolescents and children, and is dedicated to serving your

special needs and concerns. In a setting that is caring, supportive and ethical, we work to empower individuals,

couples and families to manage their own well


Patient Satisfaction

Thank you for trusting our ability to provide you with appropriate, high quality care. We make every effort to treat

each client with respect and dignity regardless of race, beliefs, national origin,

disability, or sexual preference.

If you experience a problem with any service or staff person, please discuss this with your therapist. If the situation is

not resolved, or if the nature of the concern prohibits su

The professional licensing board is also available to you.


Financial Responsibility

We request payment/co-payment at the time of service. We will submit insurance claims on your behalf. Some

insurance plans limit the number of sessions covered so you will want to understand the benefits available to you.

We are providers for most major insurance companies. However, if we are an out

to check your out-of-network benefits with your insurance company.


Initial Appointment

Your first appointment will take approximately one hour. During this appointment, y

and concerns with a mental health professional. After this initial appointment, an assessment and recommendation

for treatment will be made.


Confidential Information

Information you furnish to Northwinds Counseling Services is confidential according to the Minnesota Access to

Health Records Statute. This means that only you and your assigned therapist have access to information in your

medical chart. No treatment information will be released to persons, schools, or agencies without your consent,

except by court order.

In some cases it might be appropriate to coordinate your care with your primary care physician. If so, you will be asked

to give your written permission. For those who are using insurance, your insurance company may require diagnostic


information from Northwinds Counseling Services prior to providing payment for services.

By law, these are the exceptions to confidentiality:

 Health care providers are required by law to report cases of known or suspected abuse or neglect of children

or vulnerable adults.

 In cases of threatened homicide or serious harm, the police and possible victim must be notified.

 In cases of threatened suicide, the police will

 By law, information concerning dependent minors is accessible to the parents unless it is determined that

such access would be harmful to the minor’s well-being.


Clients under the age of 18:

All non-emancipated minor clients under the age of 18 years old must have the consent of their parents following an

initial intake session to receive further services. These rights may be waived when a minor’s life or health is believed

to be at risk, the minor is emancipated, or when in need of services relating to pregnancy, VD, or substance abuse.

As a patient, you have the right to:

 Courteous and respectful treatment.

 A safe and comfortable environment.

 Appropriate behavioral health care.

 A clear explanation of your diagnosis and treatment plan.

 Privacy and confidentiality.

 Participate in planning your care.

 Refuse behavioral health treatment.

 Be free from discrimination based on your religion, race, gender or culture.

 Register complaints.

 Access to your records as provided by law.


You are asked to:

 Treat staff with respect.

 Ask questions about your care.

 Tell your therapist everything you can about your condition, including all symptoms, medications, and past

medical history.

 Pay your bills on time.

 Keep appointments, or give at least 24 hours’ notice if you need to cancel your appointment.

 Let the therapist know about any changes in your symptoms, medications or general condition.

 Treat clinic property with care.


Emergency Procedures:

For emergency situations you can call 911, the Crisis Connection at (612)379-6363, or present at the local hospital

emergency room.


Notice of Information Practices


What is “Medical Information”?

The term “medical information” is synonymous with the terms “personal health information” and “protected health

information” (PHI) for purposes of this Notice. It essentially means any individually identifiable health information

(either directly or indirectly identifiable). Whether oral or recorded in any form or medium, that is created or received

by a health care provider (Northwinds Counseling Services), health plan, or others and relates to the past, present, or

future physical or mental health or condition of an individual (you): the provision of health care (e.g. mental health) to

an individual (you); or the past, present, future payment for the provision of health care to an individual (you).

Northwinds Counseling has mental health providers from the fields of Psychology and Marriage and Family Therapy.

Northwinds creates and maintains treatment records that contain individually identifiable health information about

you. These records are generally referred to as “medical records” or “mental health records”, and this notice, among

other things, concerns the privacy and confidentiality of these records and the information contained therein.


Uses and Disclosures Without Your Authorization — For Treatment, Payment, or Health Care Operations

Federal privacy rules (regulations) allow health care providers (Northwinds Counseling) who have direct treatment

relationship with the patient (you) to use or disclose the patient’s personal health information, without the patient’s

written authorization, to carry out the health care provider’s own treatment, payment, or health care operations. We

may also disclose your protected health information for the treatment activities of any health care provider. This too

can be done without your written authorization.


Uses and Disclosers of Your Protected Health Information That Require Your Authorization

In addition to our use of your health information for treatment, payment or healthcare operations, you may give

Northwinds Counseling written authorization, to use your health information or to disclose it to anyone for any

purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any

use of disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we

cannot use or disclose your health information for any reason except those described in this Notice.


Uses and Disclosures Authorized by Law that Do Not Require Your Consent, Authorization or Opportunity to

Agree of Object

I may use or disclose PHI without your consent or authorization in the following circumstances:

1. When the use and/or disclosure is authorized or required by law.

2. When the use and/or disclosure is necessary for public health activities. For example, we may disclose PHI

about you if you have been exposed to a communicable disease or may otherwise be at risk of contracting or

spreading a disease or condition.

3. When the disclosure relates to victims of abuse& neglect or domestic violence.

4. When the use and/or disclosure is health oversight activities. For example, we may disclose PHI about you to

a state or federal health oversight agency which is authorized to oversee our operations.

5. When the disclosure is for judicial and administrative proceedings. For example, we may disclose PHI in

response to a court order or administrative tribunal.

6. When the disclosures is for law enforcement purposes. For example, we may disclose PHI to comply with

laws that require the reporting of certain types of wounds or physical injuries.

7. When the use and/or disclosure relates to decedents. For example, we may disclose PHI to a coroner or

medical examiner, consistent with applicable laws, to carry out their duties.

8. When the use and/or disclosure relates to cadaver, organ... eye, or tissue donation purposes. Consistent with

applicable law, we may disclose health information to the organ procurement organizations or other entities

engaged in the procurement, banking, or transplanting of organs for the purposes of tissue donation and


9. When the use and/or disclosure relates to Worker’s Compensation. We may disclose relating to workers

compensation or other similar programs established by law.

10. When the use and/or disclosure is to avert a serious threat to health or safety. For example, we may disclose

P1-IT to prevent or lesson a serious and imminent threat to the health and safety of a person or the public.

11. When the use and/or disclosure relates to specialized government functions. For example, we may disclose

PHI if it relates to military and veterans’ activities, national security and intelligence activities, protective

services for the President, & medical suitability or determinations of the Department of State.

12. When the use and/or disclosure relates to correctional institutions and in other law enforcement custodial

situation. For example, in certain circumstances, we may disclose PHI about you to a correctional institution

having lawful custody of you.


Client’s Rights Regarding Protected Health Information


1. Right to Request Restrictions—You have the right to request restrictions on certain uses of disclosures of

protected health information. However, I am not required to agree to a restriction you request.

2. Right to Inspect and copy — You have the right to inspect and obtain a copy of PHI in my mental health

and billing records used to make decisions about you for as long as the PHI is maintained in the record. Under


certain circumstances, I may deny your access to PHI, but in some cases, you may have this decision


3. Right to Receive Confidential Communications by Alternative Means and Alternative Locations. For

example, you may not want a family member to know you are seeing me. On your request, I will send your

bills to another address.

4. Right to Request Amendment to PHI —Your request must be in writing and must explain your reasons for

the amendment and when appropriate to provide supporting documentation. I may deny your request under

certain circumstances.

5. Right to Request Accounting Disclosures of PHI — You have the right to a listing of certain disclosures

we have made of you PHI. You must request this in writing.

6. Right to Receive a Copy of This Notice —You have the right to request a paper copy of this Notice at any

time. I will provide a copy of this Notice on the date you first receive service from me (except when the first

contact is not in person, and then I will provide the Notice as soon as possible).


Questions or Complaints

If you have questions and would like additional information, you may contact Allen Stock at 612-7996263. There will be no retaliation for filing a complaint. You may also send a written complaint to the US Department of Health and Human Services: 200 Independence Avenue*SW Room 509F, HHH building* Washington D.C. 20201


If you are concerned that your rights were violated your privacy rights, or you disagree with a decision we

made about access to your records, you may further discuss this with your therapist. If the issued is not resolved with

your therapist, you may appeal directly to the appropriate governmental oversight resource.Type your paragraph here.