|
Natural Wellness Care
Beverly Mathiasen, ND, CBT
Complementary and Alternative Health Care
Client Bill of Rights
Please read this Complementary and Alternative Health Care Client Bill of Rights. I am pleased to provide you with this Client Bill of Rights, in accordance with Minnesota laws, Statute 146A, governing complementary and alternative health care practices.
1. Name, Title and Business Telephone Number
Beverly K. Mathiasen, ND, CBT, Owner, 763-458-5133
My services are available at:
11037 Woodhaven Ct. N. Champlin, MN 55316
2. Degrees, Training, Experience and Qualifications
Certified Biofeedback Specialist; Certified Traditional Naturopath
Licensed Biofeedback Therapist Certified Spiritual Healing Coach
In accordance with Minnesota state law, I am providing you with the following notice:
" THE STATE OF MINNESOTA HAS NOT ADOPTED ANY EDUCATIONAL AND TRAINING STANDARDS FOR UNLICENSED COMPLEMENTARY AND ALTERNATIVE HEALTH CARE PRACTITIONERS. THIS STATEMENT OF CREDENTIALS IS FOR INFORMATION PURPOSES ONLY. UNDER MINNESOTA LAW, AN UNLICENSED COMPLEMENTARY AND ALTERNATIVE HEALTH CARE PRACTITIONER MAY NOT PROVIDE A MEDICAL DIAGNOSIS OR RECOMMEND DISCONTINUATION OF MEDICALLY PRESCRIBED TREATMENTS. IF A CLIENT DESIRES A DIAGNOSIS FROM A LICENSED PHYSICIAN, CHIROPRACTOR OR ACUPUNCTURE PRACTITIONER, OR SERVICES OF A PHYSICIAN, CHIROPRACTOR, NURSE, OSTEOPATH, PHYSICAL THERAPIST, DIETITIAN, NUTRITIONIST, ACUPUNCTURE PRACTITIONER, ATHLETIC TRAINER OR ANY OTHER TYPE OF HEALTH CARE PROVIDER, THE CLIENT MAY SEEK SUCH SERVICES AT ANY TIME."
3. Practitioner's supervisor. Beverly Mathiasen is the owner/operator of Natural Wellness Care.
4. Right to file a complaint. If you have any concerns, you may file a complaint with the following office.
Office of Complementary and Alternative Practice (OCAP)
Minnesota Department of Health
P.O. Box 64975, Suite 400; Metro Square Building
St. Paul, MN 55164
DOH: 651-215-5800
5. Fees per unit of service, method of billing, names of insurance companies with reimbursement to practitioner, HMO relationships, whether practitioner accepts Medicare, medical assistance, or general assistance medical care; whether willing to accept partial payment or waive payment and in what circumstances. Fees are payable at the time of service. Should you cancel less than 48 hours before your scheduled appointment you will be charged 50% of the session fee or choose to have your session via wireless mode at full rate. If you are unable to pay the full fee at the time of service, a payment plan can be arranged. This plan must be agreed to in writing prior to the provision of services. In order to receive services, you must be current with your payment plan arrangement. We do not handle insurance claims; however, a receipt can be provided to you, should you wish to file a claim with your provider. I do not accept Medicare, Medical Assistance or General Assistance medical care.
6. Change in service or charges. You have the right to reasonable notice of changes in services or charges, and I will provide prior notice of any changes.
7. Brief summary of my Theoretical Approach. We provide alternative approaches to stress management. Beverly K. Mathiasen, ND, CBT, DBA Natural Wellness Care, makes no claim of the SCIO or ONDAMED technology or its results. The SCIO and ONDAMED biofeedback devices are used for stress evaluation purposes and stress reduction therapy only. Consult a licensed physician, psychologist, or any other licensed health care professional for diagnosis or treatment.
8. Assessment and Recommendations . You have the right to complete and current information concerning your stress assessment and suggested services, including the expected duration of the services to be provided. If you have any questions, please ask.
9. Courteous Service. You may expect courteous treatment and to be free from verbal, physical or sexual abuse by your practitioner.
10. Confidentiality. Your records and transactions with this office are confidential. This information will not be released unless you authorize release in writing, or unless release is required by law.
11. Records. You are allowed access to records and written information from records in accordance with section 144.335 of Minnesota Statutes.
12. Other Community Services. Other similar services are available in the community. Possible sources of information are Minnesota Wellness Directory, the Edge newspaper directory, or the telephone yellow pages. You may ask your practitioner and she will provide this information to the best of her knowledge.
13. Selecting and Changing Practitioners. You have the right to choose freely among available practitioners and to change practitioners after services have begun, within the limits of health insurance, medical assistance or other health programs. If these services are covered by your health insurance, medical assistance plan or other health program, you should direct all questions about coverage to your health insurance provider.
14. Coordinated transfer. If you change practitioners, you have the right to our assistance in coordinating this transfer to another practitioner.
15. Right to Refuse Service. You are free to refuse services or treatment unless otherwise provided by law.
16. No Retaliation. You may assert your rights described in this Client Bill of Rights at any time without retaliation.
ACKNOWLEDGMENT
I have received a copy of the Complementary and Alternative Client Bill of Rights. I have read and understand the Client Bill of Rights, or it has otherwise been read to me. I have had a full opportunity to ask any questions I have about this document and my rights as a client. I understand my rights as a client.
____________________________________________________
Client or Legal Guardian's Name Printed
________________________
Date
____________________________________________________
Client or Legal Guardian's Signature
________________________
Date
____________________________________________________
Relationship to Client
________________________
Date
____________________________________________________
Witness (Other than practitioner if available)
________________________
Date
|
