Client Information and Consent.

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Welcome and thank you for considering Touch Medical PLLC (“Touch Medical PLLC”, “us”, “Company”) for your medical needs. This document contains important information about our professional services and business policies and is intended to obtain your informed consent for the examination, diagnosis, and treatment. Please read this form carefully and feel free to ask your medical professional any questions you may have. Your signature indicates that you have read and understood the information provided and that you consent to the care described.

(1) Licensed Medical Professional. The medical professionals are engaged in private practice providing medical care services to clients on behalf of the Company and not in their personal capacity personally. In addition, all staff of the Company are providing services in their capacity under the Company and not personally.

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(2) Appointments. Appointments are made by calling 218-348-8044 during the normal business hours listed at {{Website}}. Please call to cancel or reschedule at least 24 hours in advance, or you may be charged for the missed appointment. Third-party payments will not usually cover or reimburse for missed appointments. If you are late, you will be charged for the full amount of the appointment if your insurance coverage allows, and there will be no pro-rating of the fee. If the Medical Professional has to cancel the appointment, you will be entitled to a refund. You shall be discharged from services after three (3) no-shows for appointments automatically.

(3) Number of Visits. The number of sessions needed depends on many factors and will be discussed by the Medical Professional. Your initial session will involve an evaluation of your needs and depending on your circumstances further evaluative sessions may be required. At the end of the evaluation process the undersigned Medical Professional will be able to provide you with some first impressions of what practice may include and a treatment plan to follow if both you and the Medical Professional agree to work together in your services. You should evaluate this information along with your own opinions of whether you feel comfortable working with the Medical Professional. If you have questions about procedures feel free to discuss them with the Medical Professional at any time. If you have doubts your Medical Professional will be happy to help you set up a meeting with another medical professional for a second opinion.

(4) Crisis or Emergency. If you have a medical emergency - contact 911 and/or visit your nearest emergency room. If you have an active suicidal plan and/or concerns about self-harm or safety, follow your harm reduction plan, if one exists, and then contact 911 and/or visit your nearest emergency room.

(5) Length of Visits. The initial intake and evaluative session is normally scheduled for one (1) hour or one hour and a half hour (90 minutes) and may run longer depending on the testing or assessments a client is asked to complete. Further evaluative sessions may be scheduled as needed for the Medical Professional to accurately assess your needs. Once the evaluation process is completed medical sessions are generally 15 to 45 minutes in length depending on the circumstances. Total length of visit shall include chart review done during and after the visit, and may not be the total actual face-to-face contact time.

(6) Cancellations. Cancellations must be received at least 24 hours before your scheduled appointment; otherwise you may be removed as a patient. You are responsible for calling to cancel or reschedule your appointment. If you miss three (3) appointments, the Company may discharge you as a patient at the Company’s discretion.

(7) Payment for Services. You are solely responsible for payment of services. Here are the current rates below:

Initial assessment (60 minutes adults; 90 minutes child/adolescent): $XX

Standard length (up to 30 minutes): $XXX

Extended length (up to 45 minutes): $XXX

These fees are subject to change upon thirty (30) days' prior notice to you. If you are unable to pay, or are not willing to pay, the higher fee after receipt of notice, services may be terminated and you may be given referrals to other competent providers. The undersigned Medical Professional will look to you for full payment of your account, and you will be responsible for payment of all charges. Different copayments are required by various group coverage plans. Your copayment is based on the Medical Policy selected by your employer or purchased by you. In addition, the co-pay may be different for the first visit than for subsequent visits. You are responsible for and shall pay your copay portion of the undersigned Medical Professional's charges for services at the time the services are provided, unless there is applicable insurance coverage in force. It is recommended that you determine your copayment before your first visit by calling your benefits office or insurance company.

(8) Medical Records and Court Appearances. Although it is the goal of the undersigned Medical Professional to protect the confidentiality of your records, there may be times when disclosure of your records or testimony will be compelled by law. Confidentiality and exceptions to confidentiality are discussed below. In the event disclosure of your records or the Medical Professional's testimony are requested by you or required by law, regardless of who is responsible for compelling the production or testimony, you will be responsible for and shall pay the costs involved in producing the records and the hourly rate charged by the Medical Professional at the time of the request or service of the subpoena (current rate is $450/hour) for the time involved in traveling to and from the testimony location, reviewing records and preparing to testify, waiting at the location, and giving testimony. Such payments are to be made at the time or prior to the time the services are rendered by the Medical Professional. The Medical Professional may require a deposit for anticipated court appearances and preparation. You will not be entitled to a pro-rated refund.

(9) Mandated Reporting. Under certain state law, persons in designated professional occupations are mandated to report suspected child abuse or neglect or maltreatment of vulnerable adults. Persons who work with children and families are in a position to help protect children from harm. These persons may be required by law to report, if they know or have a reason to believe that a child or vulnerable adult is being abused or neglected. As a mandated reporter, the mental health professional may be required to break confidentiality and report certain information to the appropriate authorities.

(10) Risks of Services. There are no guarantees in services and the Medical Professional does not make any guarantees with this agreement. The Medical Professional may take any reasonable action necessary during services when there is a dangerous circumstance, as determined by the Medical Professional. You agree to mitigate this risk by disclosing any and all relevant medical information to the Medical Professional

(11) After-Hours Emergencies. Please know that your Medical Professional and Touch Medical PLLC do not provide twenty-four (24) hour crisis or emergency services. Should you experience an emergency necessitating immediate medical attention, immediately call 911 or if you are able to safely transport yourself, go to the nearest hospital emergency room for assistance.

The COPE mobile crisis teams can come to where you are. The teams respond to anyone in the county who is having a mental health crisis and needs an urgent response. If the situation is life-threatening or you need immediate response call 911.

For other areas Mental Health Crisis Response resources are below for your use as appropriate.

Anoka: 763-755-3801, Carver/Scott: 952-442-7601Dakota: 952-891-7171, Washington: 651-777-5222Ramsey: adults - 651-266-7900, Sherburne: 800-635-8008Hennepin: adults - 612-596-1223, Stearns: 800-635-8008, Olmsted: 1-844-274-7472.Wright County - 1-800-635-8008

The Minnesota Warmline provides a peer-to-peer approach to mental health recovery, support and wellness. Calls are answered by our team of professionally trained Certified Peer Specialists, who have first hand experience living with a mental health condition.The Warmline provides a safe, anonymous and confidential environment to connect with people who are here to listen. Open Monday-Saturday, 12 PM to 10 PM Call: 651.288.0400 Toll Free 877.404.3190 or text “Support” to 85511

Lifeline Network: If you’re thinking about suicide, are worried about a friend or loved one, or would like emotional support, the Lifeline network is available 24/7 across the United States. 24/7 Call: 1-800-273-8255

Poison Control: 800-222-1222. 24-hour hotline for help with medication questions such as questions about accidental overdose, drug interactions or medication side effects.

(12) Contacting Your Medical Professional. Your Medical Professional is often not immediately available by telephone. This phone number is not a crisis line or for urgent or emergency medical care. The office number 218-348-8044‬ is answered by voicemail that the Medical Professional will monitor from time to time throughout the day. Although the Medical Professional is typically in the office during normal business hours s/he will not take calls when with a client. There is no guarantee on response times and the best time for communication at the next scheduled appointment, but the Medical Professional shall attempt to return a call within 72 hours. The Medical Professional set this up for you before your first appointment.

(13) E-Mail and Text Messages The undersigned Medical Professional and Touch Medical PLLC does not use and respond to email and text messages to respond to medical concerns. Texts and emails related to your treatment or services as electronic communications are not completely secure and confidential. Any service related questions or issues will not be addressed by the Medical Professional in any electronic communication but will be dealt with during your next session. Any electronic transmissions of information by you are retained in the logs of your service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the service providers. You should know that any e-mails, and specifically the website, are not secure and you assume the risks of the insecure transmission.

(14)Communication. I understand that Touch Medical PLLC may need to contact me to discuss services I have received, financial matters related to billing, and for future appointments or services. I consent that Touch Medical PLLC may contact me (please check the box of which forms of communication you consent to and fill in the contact information):

Email: ________________________________________________________

Home Phone: __________________________________________________

Cell Phone: ____________________________________________________

Home Address: _______________________________________________________________________________________________________________

Can staff leave a message on your phone regarding upcoming appointments? YesNo

Do you consent to text messages from Touch Medical PLLC? YesNo

(15) Social Media Your Medical Professional does not accept friend or contact requests from current or former clients on any social networking sites. Adding clients as friends or contacts on these sites can compromise confidentiality and privacy of both the Medical Professional and the client. It can blur the boundaries of the professional relationship and are not permitted. Any attempt by a client to surreptitiously gain access to the Medical Professional's personal site(s) will be cause for termination of the services.

(16) Medical Professional's Incapacity or Death You acknowledge that, in the event the undersigned Medical Professional becomes incapacitated or dies, it will become necessary for another Medical Professional to take possession of your file and records. By signing this information and consent form below, you give consent to allow another licensed medical professional selected by the undersigned Medical Professional to take possession of your file and records and provide you with copies upon request, or to deliver them to a Medical Professional of your choice. The undersigned Medical Professional will select a successor Medical Professional within a reasonable time and will notify the appointed licensed medical professional.

(17) Audio and Video Recordings You acknowledge and, by signing this information and consent form below, agree that neither you nor the undersigned Medical Professional will record any part of your sessions unless you and the Medical Professional mutually agree in writing that the session may be recorded. You further acknowledge that the undersigned Medical Professional objects to you recording any portion of your sessions without the Medical Professional's written consent. You expressly agree that audio and video recordings used for security or training purposes are not part of services, and are therefore not protected by confidentiality or any other provisions under this agreement.

(18) Legal This Agreement shall be construed in accordance with, and governed by, the laws of the State of Minnesota as applied to contracts that are executed and performed entirely in Minnesota. The exclusive venue for any court proceeding based on or arising out of this Agreement shall be the county of the medical office address. The parties agree to attempt to resolve any dispute, claim or controversy arising out of or relating to this Agreement by arbitration, which shall be conducted under the then current arbitration procedures of the American Arbitration Association any other procedure upon which the parties may agree. The parties further agree that their respective good faith participation in arbitration is a condition precedent to pursuing any other available legal or equitable remedy, including litigation, arbitration or other dispute resolution procedures. If any legal action or any arbitration or other proceeding is brought for the enforcement of this Agreement, or because of an alleged dispute, breach, default or misrepresentation in connection with any of the provisions of this Agreement, Touch Medical PLLC and the Medical Professional shall be entitled to recover legal fees and other costs incurred in that action or proceeding, including lost revenue, in addition to any other relief to which it or they may be entitled. You release Touch Medical PLLC and the Medical Professional from any good faith refusals of medical records as allowed by law.

(19) Consent to Treatment I, voluntarily, agree to receive medical assessment, care, treatment, or services, and authorize Touch Medical PLLC to provide such care, treatment, or services.

I understand that I am not guaranteed a positive outcome. I agree to follow the agreed upon treatment plan and to inform Touch Medical PLLC if I alter my treatment plan, experience side effects, or cease to follow my treatment plan.. I understand and agree that I will participate in the planning of my care, treatment, or services, and that I may stop such care, treatment, or services that I receive through Touch Medical PLLC at any time.

By signing this Client Information and Consent form, I, the undersigned client, acknowledge that I have read, understood, and agreed to be bound by all the terms, conditions, and information it contains. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.

I acknowledge that I received a copy of this signed information and consent form from my Medical Professional.

Client Signature: ______________________

Date: ______________________