Forms 

CONSUMERS OF PSYCHOLOGICAL SERVICES OFFERED BY PSYCHOLOGISTS LICENSED BY THE STATE OF NORTH DAKOTA HAVE THE RIGHT:

To expect that a psychologist has met the minimal qualifications of training and experiences required by the state law; To examine public records maintained by the North Dakota State Board of Psychologist Examiners which contain the credentials of a psychologist; To obtain a copy of the rule of conduct from, and to report complaints to, North Dakota State Board Psychologist Examiners, PO Box 7458 Bismarck, ND 58507-7458; To be informed of the cost of the professional services before receiving services; To privacy as defined by rule and law put forth in the Health Insurance Portability and Accountability Act; To be free from being the object of discrimination of the basis of race, religion, gender, or other unlawful category while receiving psychological services.

CONSUMERS OF COUNSELING SERVICES OFFERED BY ADDICTION COUNSELORS, PROFESSIONAL CLINICAL COUNSELORS, AND LICENSED SOCIAL WORKERS LICENSED BY THE STATE OF NORTH DAKOTA HAVE THE RIGHT:

To expect that an addiction counselor, professional counselor, and licensed social worker has met the minimal qualifications of training and experience required by the state law; To examine public records maintained by the North Dakota State Board of Addiction Counselor, Professional Counselor, and Licensed Social Worker Examiners, 402 E Main Ave, Ste #5, Bismarck, ND, 58501-4091; To obtain a copy of the rules of conduct form, and to report complaints to  North Dakota State Board of Counselor Examiners, 2112 10th Ave SE, Mandan, ND, 58554; To obtain a copy of the rules of conduct form, and to report complaints to, North Dakota State Board of Social Work Examiners, PO Box 914, Bismarck, ND, 58502-0255; To be informed of the cost of the professional services before receiving services; To privacy as defined by rule and law put forth in the Health Insurance Portability and Accountability Act; To be free from being the object of discrimination on the basis of race, religion, gender, or other unlawful category while receiving counseling services.

CONSUMERS OF MEDICAL SERVICES OFFERED BY PHYSICIAN ASSISTANTS LICENSED BY THE STATE OF NORTH DAKOTA HAVE THE RIGHT:

To expect that a Physician's Assistant has met the minimal qualifications of training and experiences required by the state law; To examine public records maintained by the North Dakota State Board of Medicine which contain the credentials of a Physician's Assistant; To obtain a copy of the rules of conduct from, and to report complaints to, North Dakota State Board of Medicine, 418 E Broadway Ave, Suite 12, Bismarck, ND, 58501; To be informed of the cost of the professional services before receiving services; To be free from being the object of discrimination on the basis of race, religion, gender, or other unlawful category while receiving medical services. 

TO WHOM DOES THIS NOTICE APPLY?

This notice applies to everyone who works for Agassiz Associates, including all of our employees, contractors, and information technology services. 

WHY DO WE PUBLISH THIS NOTICE?

As medical professionals, we understand that information about you and your health is sensitive and personal. We are required by law to maintain the privacy of information that we gather and use about you, as well as to provide you with notice of our legal duties and privacy practices with respect to your information. We are committed to the privacy of our clients' information. In order to serve you, we need to obtain, secure, and utilize records. We occasionally need to share information with other healthcare providers. This notice is intended to inform you about how we use and disclose your information. This notice informs you about your legal rights with respect to the information we secure about you. You have the right to review your records or obtain a copy of your records. You may request we amend your records and/or account for certain disclosures we have made of clinical information pertinent to you.

WHEN DOES THIS NOTICE BECOME EFFECTIVE?

We are required to comply with the terms of this notice while it is in effect. We reserve the right to change the terms of this notice and make the new terms effective for all information to which this notice applies.

WHAT INFORMATION DOES THIS NOTICE COVER?

This notice covers all information in our written and/or electronic records pertaining to you, your healthcare, and the payment for your healthcare.

USES AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) AND HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU:

1. TREATMENT: We may use of disclose information about you for treatment purposes to all clinical providers and staff who work in our agency who are involved in providing your healthcare.

2. HEALTHCARE OPERATIONS: We mat use of disclose information about you in connection with the operations of our practice. These activities may include quality improvement, training of gradute students, insurance underwriting, medical or legal reviews, or the administration practices of our practice. 

3. OTHER USES & DISCLOSURES: Agassiz Associates, PLLC will obtain an authorization from you before using or disclosing PHI information in a way that is not described in this notice. Agassiz Associates, PLLC maintains progress notes but does not maintain "psychotherapy notes." Agassiz Associates, PLLC does not use your PHI for marketing purposes nor does it sell any of its PHI for any reason.

WITHOUT YOUR WRITTEN CONSENT:

We may disclose information about you without your consent for the following purposes:

1. It is determined you are a threat to yourself or another per

2. In the event of suspected child abuse.

3. In litigation, subject to court order.

4. If there is a medical emergency.

5. In the event of suspected abuse or neglect of vulnerable adults.

6. As part of mandated reporting of Autism Spectrum Disorder.

REMINDERS, MARKETING, AND RESEARCH:

We may send you information to support your healthcare, including appointment reminders, alternative treatments, health related services that may be of interest to you, and follow up surveys. Please advise us in written form if you do not wish to receive this kind of communication.

We may not use of disclose information about you for any other purpose without your written authorization, provided separately from your written consent.

WELCOME TO AGASSIZ ASSOCIATES, PLLC

Agassiz Associates, PLLC (hereafter referred to as Agassiz Associates) is glad you have chosen us for your behavioral health services. This document contains important information about our professional services and policies. It also contains a summary of the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides you with privacy protections and client rights regarding the use and disclosure of your Protected Health Information (PHI) for the purpose of assessment, treatment, insurance filing, payment, and other operations involved in providing your behavioral health treatment. The Notice of Privacy Practices given to you with this agreement explains our privacy practices in detail. The law requires we obtain your signature acknowledging we have provided you with this information. This Service Agreement/ Informed Consent needs to be signed if any assessment or treatment is to be provided. It is very important you read this document and discuss any questions you have with your provider. This agreement is between you and your provider. You may revoke the agreement in writing at any time. That revocation will be binding unless Agassiz Associates has taken action in reliance on it (e.g., if there are obligations imposed on us by your health insurer in order to process or substantiate claims made under your policy, or if you have not satisfied the financial obligations incurred.)

GETTING STARTED

The first appointment involves an assessment of your treatment needs. Your provider will offer you some clinical impressions of what your treatment will provide. A treatment plan will be devised. If you have any questions, dicuss them with your provider. If you decide you would prefer a different provider, we will be happy to help you set this up and/or make a referal.

BEHAVIORAL HEALTH TREATMENT

At Agassiz Associates, we provide assessments, therapy, psychiatric medication management and substance use disorder treatment. Your treatment may vary depending on the particular issues you are experiencing. Treatment works better when you engage actively in it. In order for treatment to be effective, it is important you keep your appointments, engage in your treatment, and follow up with any recommendations made by your provider. 

RISKS & BENEFITS

Any treatment can have have risks along with the benefits. You may experience uncomfortable feelings in therapy, or have some side effects from a psychiatric medication. On the other hand, research has shown therapy and psychiatric medication, especially when combined, can result in significant benefits. Therapy often leads to better relationships, solutions to issues, and/or significant reductions in your symptoms and overall level of stress. There are no guarantees regarding exactly what you will experience. It is important to ask questions directly with your provider about your treatment. And, it is your right to have your questions addressed in a timely manner. You also have the right to discontinue services at any point in your treatment.

IN-PERSON TREATMENT SERVICES

Agassiz Associates offers most services via in-person and/or telehealth. There may be health reasons or weather-related conditions that determine the need for Agassiz Associates to require services be provided via telehealth. Reimbursement for telehealth and in-person services are determined by insurance companies and applicable law. Each provider has the option to provide services in-person, via telehealth or through some combination of both. Clients may choose to receive services in-person, via telehealth or both. We will respect your decision regarding how services are delivered if it is feasible by law, insurance reimbursement and clinically appropriate. There are inherent risks of disease transmission associated with in-person services, including the possibility of contracting Covid-19, the flu, Norovirus, Staph infections, the common cold and/or other communicable diseases. During the incubation period of many illnesses, an individual may not yet be symptomatic yet may still be contagious. Preventative measures and disinfectant protocols intended to reduce the spread of communicable diseases have been implemented at Agassiz Associates. If you show signs of fever or other symptoms of an illness, Agassiz Associates will reschedule your appointment, and ask you to leave the premises. If your provider is showing signs of a fever or other symptoms of an illness, Agassiz Associates will reschedule your appointment or change it to a telehealth appointment if the provider is feeling well enough to work (e.g., recuperating from an illness but still potentially contagious.) To minimize the risk of spreading an infectious disease, we ask you to take precautions to help protect everyone from exposure or illness. If you do not take safeguards to protect the health of others, Agassiz Associates may require you to utilize telehealth services (as available), refer you to services at another clinic or refuse to provide services. To summarize, when attending an in-person appointment at Agassiz Associates, you agree to the following:

• reschedule your appointment if you have a fever and/or symptoms of an illness,

• reschedule your appointment if you have been in close contact to someone who has been diagnosed with a highly communicable disease, or if you have been diagnosed with a highly communicable disease, 

• arrive for your appointment no earlier than 5 minutes before your appointment time,

• ensure that your child is following the same protocols (as noted above).

TELEHEALTH TREATMENT SERVICES

Telehealth services at Agassiz Associates are available for most services provided. Agassiz Associates will assist you in preparing for your scheduled telehealth appointment by providing step-by-step instructions for using our telehealth services. We recommend you become acquainted with these instructions at least two days prior to your initial telehealth session. That way, you can address any technological issues you encounter when setting up your computer or phone for the telehealth session. This also allows enough time to reschedule your appointment if you are not prepared for your telehealth session. We utilize a HIPAA compliant Zoom format for our telehealth sessions that is user friendly. It meets all criteria established for telehealth security and confidentiality. Telehealth services at Agassiz Associates occur via a HIPAA compliant synchronous interative video. State laws and regulations require clients be located within the state in which your provider is licensed. There are some inherent potential technological risks associated with telehealth services including, but not limited to, the following:

• Transmission of personal information may be disrupted or distorted by technical failures.

• Circumstances out of Agassiz Associates' control, such as poor internet connection at the client's end, a client's electronic device having a low battery, etc.

• Transmission of a client's personal infromation could be interrupted by an unauthorized person.

To guard against the technological risks, Agassiz Associates uses HIPAA complient technological software, making the communications safe and confidential on our end. You can increase your safety and privacy on your end by doing the following:

• Limit telehealth services to private locations & avoid using your work computer for telehealth.

• Restrict other people from accessing your phone, computer, or any other technological device you choose to use to participate in telehealth services. 

• Schedule your appointments at times when you are alone. 

• Do not provide confidential information via email.

• Take precautions regarding authorized and unauthorized access to the technology used during telehealth services.

• Be cautious about who (e.g., friend, family members, significant others or co-workers) has access to your computer, phone or other device you use for telehealth services.

Clients are required to provide their location at the beginning of every telehealth session to ensure local services can be arranged in case of an emergency. If you or your provider believes you would be better served via in-person delivery of treatment services, this method of delivery will be provided by your provider, or you will be referred to a provider who provides in-person services. Telehealth services are often utilized during inclement weather and/or when other issues negate the option of safely providing in-person services.

APPOINTMENT SCHEDULING

During the initial appointment, the provider and you will mutually decide if the current provider is the best person to provide the treatment recommended to meet your treatment goals. Frequency of treatment is determined by the provider and discussed with the client. Once an appointment is scheduled, you will be expected to provide at least one business day (24 hour) advance notice in order to cancel or reschedule the appointment. Exceptions will be made for emergencies or inclement weather. If you do not provide one business day (24 hour) advance notice of cancellation, or if you fail to present for a scheduled appointment, you will be charged a fee of $50.00. Insurance companies do NOT provide reimbursement for a cancelled or missed session. If repeated cancellations occur or if you repeatedly fail to present for your scheduled appointments, your provider will discuss whether or not it is beneficial for you to continue treatment and/or may refer you to a different treatment and/or provider.

CONTACTING YOUR PROVIDER

During regular business hours, our office staff will answer your call and relay any message to your provider. During non-business hours, a confidential answering service will take your call. If you are in a crisis situation and feel you cannot wait for your provider to return your call, contact the nearest emergency department immediately and ask for the psychiatrist on call, or dial 911. Additional emergency numbers: Altru ER @ 701.780.5000 or Northeast Human Service Center Crisis Line @ 701.775.0525 or dial 988 for Suicide Prevention & Crisis Support.

MEDICAL EMERGENCIES

Agassiz Associates' plan for emergency care if an individual becomes physically ill and/or is unable to move or think independently is to call emergency services to have the individual medically assessed and treated. The client will be responsible for the incurred costs for these medical services. 

FEE SCHEDULE

Varying fees are available to view upon request.

DEPOSITS REQUIRED FOR COURT ORDERED EVALUATIONS

A $50 deposit is required to scheduled a DUI/ Court Ordered Evaluation. Court ordered evaluations include those requested by the courts, attorneys, probation, or for other legal purposes. The deposit is applied to the cost of the evaluation if the appointment is kept and the evaluation is able to be completed. Deposits are NON-REFUNDABLE. If you cancel a court ordered evaluation, the deposit is forfeited. A new appointment can be scheduled if a new $50 deposit is made. 

INCONVENIENCE FEE

When personal checks are returned by the bank for insufficient funds, a $25 inconvenience fee will be assessed to your account.

FEES FOR OTHER PROFESSIONAL SERVICES NOT COVERED BY YOUR HEALTH INSURANCE

Other professional services are billed at an hourly rate. Fees are prorated in increments of 30 minutes. Examples of services not covered by insurance include on call supportive intervention sessions, consultations with professionals (requested/authorized by you), and preparation of treatment summaries or letters. If legal proceedings require the participation of your provider, you will be responsible to pay for any professional time spent on your legal matter, even if the request comes from another party but involves you. Any attorney requesting your provider give expert testimony must contact your provider first directly. Because of the complexities of legal involvement, the professional fee for court document preparation and/or attendance at any legal proceeding is billed at a higher rate. A retainer for the estimated fee is required in advance of the court proceedings. A paper copy of the rates charged for other professional services not covered by your health insurance as well as for any legal proceedings is available at the Agassiz Associates, PLLC physical location. Or, you may contact the Business Administrator at Agassiz Associates, PLLC at 701.746.6336.

BILLING FOR SERVICES

We require an automatic payment plan be completed prior to your first appointment. You will receive a montly statement of your account activity. Please note that whomever signs as parent/legal guardian for treatment services for a minor is 100% responsible for the costs of treatment. We accept cash, check, money orders, Discover, Master Card, and Visa for payments. There is a $10.00 minimum for running all credit/debit cards. Credit balances greater than $25.00 upon completion of treatment will be reimbured to the client.

HEALTH INSURANCE

We offer a free verification of health insurance benefits. We will file all of your treatment sessions with your insurance company. All resulting charges post insurance payments are your responsibility. Your contract with your health insurance and/or other payor requires us to provide information relevant to the services provided. This includes a clinical diagnosis. On occasion, insurance companies require additional clinical information such as treatment plans, summaries, or copies of your entire clinical record prior to approving payment for treatment. In such situations, we make every effort to release the minimum amount of information necessary to fulfill the request. Though all health insurances and/or other payors are required to keep such information confidential, Agassiz Associates has no control over what they do with your records. Upon your written request, we will provide you with information related to any health insurance and/or other payor request for records. By signing this agreement, you are agreeing that Agassiz Associates can provide the requested clinical information to your health insurance and/or other payor. You have the right to pay for your treatment yourself to avoid disclosing your clinical records to your health insurance and/or other payor.

CONFIDENTIALITY & YOUR RECORDS

Professional laws and standards require all PHI be kept in your clinical record. Pursuant to HIPAA, this includes information about your reasons for seeking treatment, a description of the stressors and/or issues impacting your life, any diagnoses, treatment goals, progress notes, medical and social history, your treatment history, treatment records received from other providers, reports of professional consultants, billing records, and any reports that have been sent out. You have the right to examine and receive a copy of your records if you request so in writing. Professional records can be misinterpreted. For this reason, you must review your records in the presence of your provider or have your clinical record forwarded to another provider in order that you can discuss and understand the clinical content. Agassiz Associates is allowed to charge a copying fee of $20.00 for the first 25 pages and 75 cents per subsequent page of paper records. Agassiz Associates operates in a hybrid manner, utilizing both electronic and paper health records in order to maintain and release its clinical records. Therefore, charges may apply for records requests if an electronic copy cannot be easily produced. 

The law protects the privacy of all communications between client and provider. In most situations, Agassiz Associates can only release information about your treatment to others if you sign a written authorization form that meets the legal requirements of HIPAA. Some situations require you to provide advance written consent.

• Your provider may occasionally desire to consult with other healthcare professionals about your treatment. Your provider will make every effort to avoid revealing your identity. Other professionals are legally bound to keep the consultation information confidential. You will not be told about these consultations made in your best treatment interests unless your provider feels it is important for your treatment. Your provider will note all consultations in the PHI contained in your clinical record. 

• Your provider practices with other mental health professionals and administrative employees. It is necessary to share basic protected health information with these individuals for both clinical and administrative purposes (e.g., case consultation, scheduling, billing, quality assurance, etc.). All mental health professionals are bound to keep your clinical record confidential. All staff members have been trained regarding HIPAA and Agassiz Associates' policies and procedures which spell out the requirement for them to protect your privacy. 

• Agassiz Associates contracts with various businesses including but not limited to an answering service, an accounting firm, an electronic health record company, and the owners of the building where Agassiz Associates operates its business. As required by HIPAA, for Business Associates Agreements have been signed with these businesses requiring them to maintain the confidentiality of all data except as specifically allowed in the agreement or otherwise required by law.

• Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this agreement. 

• If you threaten serious harm to yourself, your provider is required to take action to facilitate your safety. This includes possible hospitalization and/or contacting family members or others who can help you maintain your personal safety. 

• Although Agassiz Associates follows guidelines to try to ensure your confidentiality, there are inherent risks in using technologies that interact with cloud based or cellular communication systems. Agassiz Associates uses a cloud-based telephone system that supports our providers to use cellular devices to return emergency or crisis calls.

The following are situations in which your provider is permitted or required to disclose your clinical information without either your consent or authorization.

• If you are involved in a court proceeding and a request is made for clinical information concerning your evaluation, diagnosis and/or treatment, such information is protected by physician and mental health  professional patient privilege. Your provider cannot provide any clinical information without your written authorization unless a court order is provided. If you are involved in or contemplating litigation, you should consult first with your attorney to determine whether a court may be inclined to order your provider to disclose your clinical information.

• If a government agency is requesting information for health oversight activities, your provider may be required to provide for them.

• Autism Spectrum Disorder (ASD) mandated reporting. According to North Dakota Century Code 23-01-41 and Administrative Code 33-03-34, ASD is a mandatory reportable condition and must be reported within 30 days of diagnosis, or if previously diagnosed, within 30 days of the first client encounter with the mandated reporter.

• If a client files a complaint or lawsuit against his or her provider, the provider may disclose relevant clinical information regarding that client to defend themself.

• If a client files a worker's compensation claim, the provider must, upon appropriate request, provide appropriate clinical information including a copy of the client's record or other information concerning mental health care services to the requesting payor.

There are situations in which your provider is legally obligated to take action in order to protect you or others from harm. This may require revealing some clinical information about your treatment.

• If your provider suspects that a child or vulnerable adult is being abused or neglected, the law indicates that your provider must file a report with the Department of Human Services. Once such a report is filed, your provider may be required to provide additional clinical information.

• If you threaten serious physical harm to an identifiable victim, your provider is obligated to take action to protect the potential victim. Such action may include contacting the police or seeking hospitalization for you.

• If a situation requiring your provider to make a report arises, your provider will make every effort to discuss it with you before taking any action and will limit any disclosure to what is absolutely necessary.

• It a client has a medical emergency, the provider will contact emergency services.

It is important you discuss any questions or concerns you may have about the confidentiality of your treatment with your provider. The laws governing confidentiality are complex. Agassiz Associates recommends you consult an attorney in situations where legal issues are involved.

CONFIDENTIALITY & TREATMENT FOR MINORS

Clients under the age of 18, who are not emancipated, should be aware that the law may allow parents to examine their treatment records unless the provider decides that such access not in the best interest of the minor, or you both agree otherwise. The Privacy Rule indicates parents generally have the authority to make health care decision about their minor children. There are three exceptions to this provision:

1. If a state law allows a minor to access mental health services without the consent of a parent.

2. When a court makes the determination or a law authorizes someone other than the parent to make health care decisions for the minor.

3. When the parent of guardian assents to an agreement of confidentiality between the provider and the minor.

If one of these exceptions applies, the Privacy Rule makes it clear that, although records do not have to be disclosed, the minor may still voluntarilty choose to involve a parent or adult as a personal representative. However, the minor maintains the exclusive ability to exercise their rights under the Privacy Rule. 

Because privacy is often crucial to successful treatment, it is sometimes the policy of your provider to request an agreement from parents to not access their child's records. If they agree to this, the provider will provide them only with general information about the progress of the child's treatment and their attendance at scheduled treatment sessions. Other communication requires the child's authorization unless the provider feels the child is in danger or is a danger/threat to someone else. In such a case, the provider will notify parents immediately regarding any concerns. The provider will discuss the matter with the minor, if possible, and address any objections they may have.

CONFIDENTIALITY OF MINORS REGARDING SUBSTANCE USE DISORDER TREATMENT

In North Dakota clients age 14 or older may contract for and receive evaluation or treatment for alcoholism and/or drug absue without permission, authority, or consent of a parent or guardian (NDCC14-10-17). If a client acting alone can legally consent to treatment, writeen authorization may only be given by the client (including disclosures to parents). If state law requires parental consent (ND under age 14), written authorization must be given by both the parent/guardian and the client. If state law requires parental consent, the client's application for treatment may be disclosed to the parent only if the client  1) has given authorization, or 2) lacks capacity to make rational choice and poses a threat to self or others (Federal Regulation 42 CFR, Part 2).

PATIENT RIGHTS

HIPAA provides you with your rights regarding your clinical record and disclosures of PHI. These rights include requesting your provider  amend your record, requesting restrictions on what information from your clinical record is disclosed to other, receiving confidential communications by alternative means and at an alternative location, requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized, determining the location to which protected information disclosure are sent and having any complaints you make about policies and procedures recorded in your clinical record. You have the right to a paper copy of this Service Agreement/ Informed Consent as well as a copy of Agassiz Associates' Notice of Privacy Practices. Your provider is willing to discuss these rights with you.