Please read this Client Bill of Rights Thoroughly. If you have any difficulty reading or understanding this document, please inform me (Zashata L, Burton), and reasonable accommodations will be made for you. This information is given to you to help you understand my qualifications and the services I provide. If you have any questions, please discuss them with me. This signed copy is required for my files.
Name: Zashata L. Burton MS, MA, LADC (Owner/Director of Moment to Moment Healing Alternatives, LLC)
520 10th Street, Suite 100 Red Wing, MN 55066
CREDENTIALS AND EDUCATION
Master of Arts (Holistic Health Studies at St. Catherine University—December 2017)
Master of Science (St. Cloud State University, MN 1994)
Bachelor of Elective Studies (St. Cloud State University, MN 1991)
Licensed Alcohol and Drug Counselor (MN License #300116/MN Board of Behavioral Health & Therapy: firstname.lastname@example.org)
According to Minnesota Law you also have the right to examine public records maintained by the MN
Board of Behavioral Health and Therapy that contain the credentials for the provider (email@example.com).
Professional Philosophy for Health and Well-Being
Healing begins with you. You play an essential role in your healing process, as well as in the treatment and services you receive. It is my goal to preserve and enhance the dignity of each person requesting and receiving services. Services are offered regardless of race, color, creed, religious preference, sex, marital status, age, ethnic origin, sexual orientation, or disability, including AIDS or HIVS status. Our professional and healing relationship begins upon our initial contact.
Right to a 2nd Opinion (Relevant only to Chemical Use/Health Assessments): According to Minnesota State law you have a right to seek a second opinion/assessment if you disagree with the recommendations of the CD Assessment you received on this date.
Access to Your Records: You have the right to current information concerning assessment, treatment, and expected duration. Under Minnesota Law you may review any information in your health record regarding any diagnosis, treatment, progress, and recommendations. Requests must adhere to the following:
- The request must be in writing
- Moment to Moment Healing Alternatives and Zashata L. Burton may not re-release any documents that were created/generated by another person or agency unless you sign a Release of Information form
- Zashata L. Burton (MS, MA, LADC) will determine if the information you request could be detrimental to the physical or mental health of yourself or is likely to cause harm to another person
- Zashata L. Burton must give you copies of your records or copies of a summary of the information in the requested records
- Records shall be provided at no cost
- If you request to view your client chart/record, Zashata L. Burton must be with you and will read the specific area of the chart you wish to review. She will be available to answer any questions you may at the time during the review process
Ethical Treatment: You have the right to be treated with integrity, and the utmost respect, and courtesy as well as treatment that is free from verbal, physical and sexual abuse. This includes (1) the right to be free from being the object of unlawful discrimination while receiving any services provided, and (2) the right to be free from exploitation for the benefit or advantage of Zashata L. Burton (Moment to Moment Healing Alternatives).
Confidentiality/Privacy of Records: Your records and transactions with me are confidential, unless release of these records, orally or verbally are authorized by you in writing, or otherwise required by law (MN Statute section §144.335).
Release of Information: You have the right to know and understand the intended recipients of any protected health services received, including assessments, by Zashata L. Burton (Moment to Moment Healing Alternatives). You will be asked to sign specified Release of Information forms and will be given information pertaining to Federal or State Law exceptions related to protection of health information. You also have the right to withdrawal consent to release protected health information, unless that right is prohibited by law, a court order or was waived by prior written agreement.
Cancelation of Appointments or Change in Fees By Provider: You have the right to reasonable notice of changes in services and/or charges.
Complaints: Please contact me with any questions, concerns or complaints that you have. If you feel your complaint can not be addressed with myself, you have the right to contact the following MN State agency:
For Alcohol and Drug Counseling Sessions or Assessments contact:
Minnesota Board of Behavioral Health and Therapy
2829 University Avenue SE, Suite #210
Minneapolis, MN 55414
MN LADC License Number for Zashata L. Burton is: 300116
Fees/Services: If paying by Cash or Credit Card fees/payment are due at the time service is provided.
$135.00 Substance Use Assessment (If paying by cash)
$141.75 Substance Use Assessment (If paying by credit card)
$55.00 Individual Substance Abuse Counseling (If paying by cash)
$55.75 Individual Substance Abuse Counseling (If paying by credit card)
Limited Insurance Accepted: 1) South Country Health Alliance and 2) Blue Cross Blue Shield (If policy is within clinician’s provider network)
Substance Abuse Assessments will generally take around 75 minutes to complete with your assessor. Your assessor will gather a combination of demographic information, as well as information pertaining to six significant life areas that may or may not be impacted by use of alcohol or other non-prescribed mood-altering substances. Collateral information from other sources, such as probation, attorney, significant other, other family members, may be needed to complete the assessment. For each collateral contact person or agency, you will be asked to sign a release of information form. Once your assessment is completed your assessor will send resulting recommendations to you and anyone else you have asked the recommendations to be sent to. Recommendations will be written in a manner that is easily understood and interpreted.
Individual Substance Abuse Counseling sessions are scheduled according to the individual needs of each person. You will work with your counselor, Zashata L. Burton to develop an Individual Treatment Plan. This initial treatment plan is developed primarily based on the results of your Substance Abuse Assessment. This plan will then be reviewed, and potentially revised with you on a weekly basis.
Other Resources: Other community resources are available and may be found in local newspapers and the yellow pages. Where and when appropriate I will make referrals to appropriately qualified health care practitioners to further assist you in your process. Following through on these referrals is your responsibility. You have the right to choose freely among practitioners and to change practitioners at any time. The right to refuse services is honored and no retaliation will be done if you need to assert your rights.
Termination of Services:
Zashata L. Burton (Moment to Moment Healing Alternatives) has the right to terminate a session, telephone contact or other contact because of abusive language or behavior, physical threats to staff or property, sexual or any other form of harassment, when a client is under the influence of alcohol or other intoxicant, and for any other reason necessary to assure respect for and protection of staff, or other clients. This holds true, except as otherwise provided by law or court order.
HIPAA NOTICE OF PRIVACY PRACTICES
PRIVACY OF ALCOHOL AND DRUG ABUSDE RECORDS
The United States government created new rules for the use of protection of medical and health information. The rules are the result of the 1996 Health Insurance Portability and Accountability Act (HIPAA), including the rule that I must provide all clients with a Notice of Privacy Practices to explain how client (your) information is used. This same rule requires that I keep records showing that you have received this notice.
Protected Health Information (“PHI”) may not be used or disclosed in violation of the Health Insurance Portability and Accountability Act (“HIPAA”) Privacy Rule (45 CFR, Parts 160 and 164), (hereinafter the “Privacy Rule”) or in violation of state law.
I am permitted, but not mandated under the Privacy Rule to use and disclose PHI without patient consent or authorization in limited circumstances. However, state or Federal law may supercede, limit, or prohibit these uses and disclosures.
Under the Privacy Rule, these permitted uses and disclosures include those made:
- To the client;
- For treatment, payment, or health care operations purposes; OR
- As authorized by the client.
I will also obtain an Authorization from you before using or disclosing:
- PHI in a way that is not described in this Notice;
- PHI for marketing purposes;
- PHI in a way that is considered a sale of PHI.
Additional permitted uses and disclosures without your Consent or Authorization include those related to or made pursuant to:
- Reporting on victims of domestic violence or abuse, as required by law;
- Court orders;
- Workers’ Compensation laws;
- Serious threats to health and safety;
- Government oversight (including disclosures to a public health authority, coroner or medical examiner, military or veterans’ affairs agencies, an agency for national security purposes, law enforcement);
- Health research; OR
- Marketing or fundraising.
The use and disclosure without your Consent or Authorization is allowed under other sections of Section 164.512 of the Privacy Rule and the State’s confidentiality law. This includes certain narrowly-defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a State Department of Health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.
I do not use or disclose PHI in ways that would be in violation of the Privacy Rule or state law. I use and disclose PHI as permitted by the Privacy Rule and in accordance with state or other law. In using or disclosing PHI, I meet the Privacy Rule’s necessary requirement, “as appropriate.”