Informed Consent for Authorization of Benefits

For your convenience you may complete forms in our office or electronically online.

Effective Living Center, Inc.
821 West St. Germain
St. Cloud, Minnesota 56301

I hereby instruct and direct my Insurance Company to pay by check made out to and mail to:

Effective Living Center, Inc., 821 West St. Germain St. Cloud, MN 56301

for the professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. THIS IS DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment.

A photocopy of this assignment shall be considered as effective and valid as the original.

I also authorize/consent to the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case.

This informed consent of release of information will remain in effect for a period of one year.

I authorize a doctor to initiate a complaint to the Insurance Commissioner, for any reason on my behalf.

• Prohibition of Re disclosure: This information has been disclosed to you from records whose confidentiality is protected under the Federal regulations governing Confidentiality and Drug Abuse Patient Records, 42 C.F.R, Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. pts 160 & 164. Federal Regulations prohibits you from making any further disclosures of this information except with the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations. A general authorization for the release of information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
• However, HIPAA requires ELC to notify me - the client - of the potential that information disclosed pursuant to this authorization might be re disclosed by the recipient and is longer protected by the HIPAA rules.
  
  For disclosures other than for treatment, payment and health care operations purposes, treatment may not be conditioned on my agreement to sign an authorization (unless I am receiving care solely to create protected health information for disclosure to a third party).