Client Informed Consent for Treatment and Privacy Practices

We respect and protect your privacy in accordance with the Health Insurance Portability and Accountability Act (HIPAA), the Minnesota Health Records Act, and other applicable federal and state privacy laws.

Your protected health information (PHI) may be used or disclosed without your prior written consent for the following purposes:

• Treatment: To coordinate or manage your care with other providers involved in your treatment.
• Payment: To bill and collect payment from you, your health plan, or a third-party payer.
• Healthcare Operations: For clinical supervision, training, quality improvement, and business administration.

Other disclosures without consent may occur if required by law, including:

• Reporting suspected abuse or neglect of a child, vulnerable adult, or elder
• Preventing a serious threat to your health or safety or that of another
• Compliance with a valid court order, subpoena, or governmental audit
• Required reporting to licensing or regulatory authorities

Unless otherwise required by law, we will not release your records to any third party without a valid Release of Information (ROI) signed by you or your authorized representative.

Method of Information Collection

We collect your information through:

• Intake forms and documentation completed by you or your guardian
• Clinical notes and assessments generated during appointments
• Communications through secure platforms (e.g., client portal, encrypted email, telephone)
• Claims data and insurance information
• External documentation received through coordination of care

Purpose of Data Collection

We collect and retain your data to:

• Develop and provide appropriate clinical care
• Ensure continuity of care with other providers under appropriate authorization
• Process insurance claims and manage billing
• Comply with legal, accreditation, and licensing standards
• Monitor treatment progress and support clinic-wide clinical improvement efforts

Data Security Measures

To protect your privacy, Duluth & St. Cloud TMS maintains rigorous safeguards, including:

• Encrypted, HIPAA-compliant data storage systems
• Secure electronic communications platforms
• Limited access to PHI restricted to trained, authorized personnel
• Regular staff training on privacy and compliance procedures

Data Sharing

We will never sell or use your personal health information for marketing purposes. Your data may be shared only when:

• Coordinating care with other licensed professionals under a valid ROI or BAA
• Required for insurance claims or prior authorizations
• Legally mandated by subpoena, audit, or public health requirement
• Needed in an emergency to prevent imminent harm

User Rights

You have the following rights under HIPAA and state law:

• Access: You may request to review or obtain a copy of your medical record.
• Amendment: You may request corrections to your health record.
• Restrictions: You may request limits on disclosures of your PHI.
• Confidential Communication: You may specify preferred contact methods.
• Revocation: You may revoke authorizations at any time in writing, unless action has already been taken based on your prior consent.

SMS Communication

You may opt to receive SMS communications for appointment reminders or administrative messages. By opting in, you agree to receive communication via your phone. Standard text messaging rates may apply. To stop messages, reply "STOP." To request help, reply "HELP" or contact the clinic.

Consent to Receive Electronic Notifications

I authorize Duluth & St. Cloud TMS to send me electronic communications, including appointment reminders, administrative messages, and client portal notifications, via email and/or text message to the contact information I have provided. I understand that standard message or data rates may apply, and it is my responsibility to be aware of any fees that may result from my mobile carrier. I may opt out of these communications at any time by following the instructions provided in the message or by contacting the clinic directly. It is also my responsibility to inform Duluth & St. Cloud TMS of any changes to my contact information to ensure continued delivery of important communications.

Private Pay and Personal Balances

Clients who choose to be Private Pay are required to have an active form of payment on file or provide cash or check prior to the appointment. Accepted forms of payment include cash, credit cards, debit cards, HSA/FSA cards, and checks. A sliding fee scale for each service is determined prior to beginning an appointment, but it can change if appointments run longer than anticipated, or if more work is required than first acknowledged.

If I choose to have Duluth & St. Cloud TMS submit claims to my insurance provider on my behalf, I will provide a current copy of my insurance card and a valid photo ID. I understand that if my claims are denied for any reason – including ineligibility, termination of benefits, coordination of benefits issues, or lack of coverage – I am responsible for payment in full. In such cases, I authorize the clinic to charge the outstanding balance to the card on file. The clinic will attempt to notify me of any unpaid claims requiring my attention and will provide guidance for resolving insurance-related issues.

To ensure timely and efficient billing, all clients with balances that populate will either need to have a credit card on file or an updated, accurate payment plan with Duluth & St. Cloud TMS. By signing this agreement, I authorize the clinic to charge my card for any amounts owed, including but not limited to session fees, missed appointment charges, late cancellations, co- payments, coinsurance, deductibles, and any services not covered by insurance. It is my responsibility to update the clinic promptly if my card information changes.

Insurance

I authorize Duluth & St. Cloud TMS to release any medical information necessary to my insurance company for the purpose of processing claims, and I authorize my insurance carrier to assign benefits directly to the clinic. I understand that I am ultimately responsible for payment of all services provided by Duluth & St. Cloud TMS, regardless of my insurance status, including but not limited to deductibles, co-payments, coinsurance, and any non-covered or denied services.

If my insurance coverage changes or is terminated during treatment, I agree to notify the clinic immediately. In the event I discontinue services for any reason, I acknowledge that I remain financially responsible for all charges incurred up to that date. I release Duluth & St. Cloud TMS and its providers from liability for any adverse outcomes arising from failure to notify the clinic of changes to my health condition, coverage, or contact information. I understand that this financial agreement exists between me and my insurance company, not between Duluth & St. Cloud TMS and my insurer. If preauthorization is required by my health plan, I confirm that I will discuss this with the clinic and provide necessary information so the team can properly obtain a prior authorization.

Billing Codes

I acknowledge that the clinic's providers independently determine the appropriate billing codes for services rendered. I may not request alternative coding to influence out-of-pocket costs. Charges submitted by Duluth & St. Cloud TMS reflect services performed and cannot be modified upon client request. I agree to pay any resulting patient responsibility not covered by my insurer.

Documentation

If I request the preparation of documentation – such as reports, letters, or forms – I understand these services require professional time and may involve a review of clinical records or consultation. These will be done through an appointment, or they will be considered private pay. Charges range from $25 to $250 depending on the nature and complexity of the request.

Court

In the rare event that a provider is required to appear in court, I understand that court testimony is not included in standard treatment and will incur the following fees, due two weeks in advance of the court date: $250 per hour for therapists (minimum eight hours, or $2,000) and $400 per hour for medication prescribers (minimum eight hours, or $3,200). If I cancel the appearance at least three business days prior to the scheduled date, 50% of the payment will be refunded. Cancellations made less than 72 hours before the hearing are non-refundable.

Returned Checks

A $30 processing fee will be charged for any returned checks. If this occurs, future payments must be made via cash, credit card, or an approved electronic payment method.

Appointment Cancellations and No-Show Policy

Medication Management and Therapy appointments missed without prior 24-hour notice may result in a cancellation fee of $50. A no-show fee of $75 will apply to appointments missed without any notice.

I understand that this is my responsibility to pay, as it is not covered by insurance. The clinic reserves the right to terminate individuals that No-Call-No-Show. Missing 2 or more appointments within a 12-month period can significantly disrupt treatment plans and impact access to care due to the lost appointment. If patients choose to abandon care by not showing to scheduled appointments, treatment will be terminated. All of this can be avoided, so please communicate with the team accordingly.

Telehealth Consent

I consent to participate in telehealth services with Duluth & St. Cloud TMS. I understand that telehealth may include assessments, consultations, and therapy, delivered through audio, video, or other electronic means.

I understand my rights regarding telehealth services, including:

• I can withdraw consent at any time without impact on future care.
• Confidentiality laws apply, with required exceptions (e.g., abuse reporting). Potential risks of telehealth include technology disruptions or unauthorized access. The platform that we use is encrypted.
• Telehealth may not be as comprehensive as in-person therapy, and my provider may need to refer to in-person care if needed.
• While telehealth may be beneficial, outcomes cannot be guaranteed.
• I can access my records upon request.
• I understand that telehealth is not suitable for emergencies. In such cases, I will call 911 or use crisis contacts provided above.

Authorization for Electronic Prescription Services

I authorize Duluth & St. Cloud TMS to transmit, receive, and update my prescription information electronically through a secure electronic prescription network. This includes sending prescriptions to my designated pharmacy and receiving prescription history or medication updates from other healthcare providers involved in my care.

This authorization is voluntary and may be revoked by me in writing at any time. I understand that any revocation will not affect actions taken prior to the date the revocation is received by Duluth & St. Cloud TMS.

I acknowledge that my prescription information is protected under applicable federal and state privacy laws, including HIPAA, and will only be used or disclosed for treatment, payment, healthcare operations, or as otherwise required by law.

Disclosure of Medical History and Controlled Substances Policy

I acknowledge that full and accurate disclosure of my medical and mental health history is essential to the safe and effective treatment I receive at Duluth & St. Cloud TMS. This includes information about all current and past medical or psychiatric conditions, previous treatments (inpatient or outpatient), and all the medications I am currently taking or have previously taken, especially those that could interact with my care. I agree to provide this information truthfully and completely.

I understand that it is my responsibility to disclose the use of all prescribed medications, including controlled substances such as stimulants, opioids, benzodiazepines, ketamine, suboxone, methadone, and any other substances that may impact my treatment. I also agree to inform the clinic of any history of alcohol or substance use, and I understand that omitting or falsifying this information may pose serious risks to my safety and could result in immediate termination of care at the discretion of my provider.

Duluth & St. Cloud TMS providers do not routinely prescribe controlled substances, including benzodiazepines (e.g., Ativan, Xanax, Klonopin), stimulants (e.g., Adderall, Concerta, Vyvanse), and sedative-hypnotics (e.g., Ambien, Lunesta). If treatment with these medications is needed, I may be referred to another qualified provider. Should I begin taking any controlled substance during treatment, I agree to notify Duluth & St. Cloud TMS immediately to ensure safe and appropriate care.

By signing this document, I confirm my understanding of these policies and consent to treatment with the knowledge that open and honest communication is required for my safety and successful care.

Client Informed Consent for Treatment & Notice of Privacy Practices / Confidentiality

Information shared in therapy and clinical services is considered confidential and, in most cases, is legally protected under federal and state privacy laws, including HIPAA. However, there are specific situations where Duluth & St. Cloud TMS may be required to disclose your confidential information without your prior consent or authorization. These situations include, but are not limited to:

• When we have reason to believe there has been abuse or neglect of a child, elder, or vulnerable adult.
• When we believe there is a risk of serious harm to yourself or another person, or if you are unable to safely care for yourself.
• When we are served with a valid court order, subpoena, or other legal directive requiring the release of information.
• When your insurance company or other third-party payer requires clinical information for the purpose of reimbursement, authorization, audit, or appeal.
• When a licensing board or regulatory authority requires access to records for compliance, disciplinary, or investigative purposes.
• When disclosure is required by any applicable federal, state, or local statute, rule, or law.

In accordance with Minnesota regulations and our clinic's commitment to maintaining high- quality care, clinical sessions may occasionally be observed by licensed peers or supervised students for training and quality improvement purposes. You will always be informed and asked to provide written consent before any observation or shadowing occurs.

Release of Records

All client information is treated as confidential and will not be disclosed to any individual or organization without the client's prior written authorization, except as permitted or required by law. In the event of a request to release or transfer records, Duluth & St. Cloud TMS will release documentation only after receiving a properly completed and signed Release of Information form from the client or legally authorized representative. Clients should be aware that communication via email or text is not considered fully secure, and complete confidentiality cannot be guaranteed when using these methods.

Recordings

Audio, video, or any other electronic recording of clinical services by clients is strictly prohibited without the express written consent of Duluth & St. Cloud TMS. Unauthorized recording may result in immediate termination of services. If recordings are to be made by clinic staff, they will only occur with the client's prior knowledge and written consent, typically for purposes such as client-requested documentation, supervision, or training.

Informed Consent for Therapy

Therapy can be a powerful and effective tool for change, but it also carries risks. While many individuals experience positive outcomes, there are no guarantees of specific results, such as symptom resolution or life improvements. Some clients may find that therapy brings up difficult emotions, memories, or experiences that can temporarily increase distress. In rare cases, symptoms may worsen, and additional support, including hospitalization, may become necessary.

Clients may also experience changes in how they view themselves or others, which can feel unsettling during the course of treatment. Despite these challenges, therapy can lead to meaningful benefits such as improved coping skills, increased insight, more satisfying relationships, emotional relief, and personal growth. Clients are encouraged to openly discuss their goals, expectations, and concerns with their therapist throughout the therapeutic process.

Code of Conduct

Duluth & St. Cloud TMS is dedicated to providing a safe, respectful, and professional environment for both clients and staff. In support of these values, all clients and visitors are expected to refrain from behaviors that disrupt clinical care or create an unsafe or hostile atmosphere. The following behaviors are not permitted and may result in immediate dismissal from the clinic or termination of individual services:

• Use of profane, disrespectful, or demeaning language
• Verbal arguments or confrontations with staff or other clients
• Violation of personal or professional boundaries
• Uncontrolled outbursts of anger
• Insensitive or inappropriate comments regarding others' health, appearance, or circumstances
• Destruction of property, including throwing or breaking items
• Use or threat of physical force against staff, clients, family members, or providers
• Threatening behavior directed toward any individual or the clinic as a whole

We reserve the right to take appropriate action, including contacting law enforcement, in response to any threatening, violent, or disruptive conduct.

Emergency Services

Duluth & St. Cloud TMS is not an emergency clinic, and there is no guarantee to discuss ongoing care with your provider outside of an appointment. If you are experiencing side effects from a treatment or medication received at our clinic during regular business hours, please contact the clinic and we will aid you as much as possible. Text messages, voicemails, and the patient portal are checked throughout the day.

If you cannot connect with the team during regular business hours, and you experience what feels like an emergency, please go to your local hospital, call 911, your medical group, or your primary care physician. Clinicians and employees are not available after hours. Below is a list of some crisis phone numbers:

• Suicide & Crisis Lifeline: 988
• St. Louis County (Duluth) Crisis Response: 844-772-4724
• Sterns County (St. Cloud) Crisis Response: 800-685-8008
• Crisis Counselors Text: 741741
• General Emergency: 911

Independent Contractor Notice

Duluth & St. Cloud TMS may partner with independently contracted providers who deliver clinical services under a collaborative agreement. While clients are scheduled and billed through Duluth TMS, LLC, the rendering provider may be operating independently through their own private practice. This model is designed to support providers with administrative services while maintaining consistent and accessible care for clients.

As part of this arrangement, clients are still required to complete forms under Duluth & St. Cloud TMS and may receive letters from the clinic. This is necessary for treatment and does not alter the provider's independent clinical role. The use of Duluth & St. Cloud TMS letterhead or participation in clinic operations does not change the nature of the independent contractor agreement.

Each provider retains full autonomy in how they manage their clients' care, including clinical decisions, referrals, and transitions to other providers or practices as appropriate. Duluth & St. Cloud TMS will not interfere with or restrict these decisions.

If a client no longer wishes to continue with their current provider, they may request to transition care to another provider without any negative impact to either party. If a client is discharged from the caseload of an independently contracted provider, this does not automatically remove the client from receiving care at Duluth & St. Cloud TMS. It may be possible to continue your behavioral health care at this clinic, depending on clinical appropriateness and provider availability.

Clients Rights and Consent for Services

I have read and understand the policies above. I further understand the information I have given is to be used for management purposes and the clinic will ensure confidentiality. I may inquire about or object to the methods and or type of information stored. My rights are protected under the State and Federal Confidentiality laws, the Minnesota Bill of Rights, and HIPAA requirements. A copy of these rights may be obtained through request.

I give Duluth & St. Cloud TMS my consent to supply evaluation, treatment, and other services as we mutually decide to be proper. I am taking part voluntarily, and I understand my right to refuse or stop treatment at any time. I have had the opportunity to discuss my reasons for seeking services and I understand my responsibilities in the relationship I have with Duluth & St. Cloud TMS.

Right to Revoke: You will have the right to revoke this consent at any time by giving us a written notice of your revocation. Please understand that revocation of this Consent will not affect any action we took in reliance of this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

TMS is prescribed and directly supervised by psychiatrists who are trained in TMS. It is administered by trained TMS technicians who are familiar with different TMS protocols but may only administer exactly what is prescribed. They are not clinicians and may not make treatment recommendations; they administer TMS all day every day and are trained to handle an emergency. Physician supervision takes place in many ways.

Treatment progress is checked through patient rating scales and follow-up appointments. Rating scales are required for data collection and insurance coverage determinations. If there is some uncertainty about whether to continue TMS or change the protocol, the technician will contact the physician for directions.

Risks and Discomforts

TMS has been used worldwide since 1985 and FDA approved since 2008; however, there are a series of adverse effects that may occur from TMS.

I understand the following adverse effects are possible:

1. Up to 10% of patients undergoing TMS experience headaches, face pain, jaw pain, tooth pain or neck pain. You can take ibuprofen, acetaminophen, or aspirin, which in most cases relieve the pain. Almost all patients find TMS to be tolerable.
2. TMS produces a loud clicking noise during stimulation, which can result in tinnitus or hearing loss especially if ear protection is not used. To prevent risk of hearing disturbances, earplugs will be given to wear.
3. TMS can induce a seizure even in the absence of brain lesions, epilepsy, or other risk factors for seizures. The overall risk for seizures during TMS is not known but it is less frequent than 0.5% or 5 in 1,000 patients. TMS does not cause epilepsy. In patients with known epilepsy, the risk is 1%.
4. TMS could potentially cause unintended teeth clenching, biting of the tongue, and chipping teeth. The overall risk for this is not known. If this occurs, we will supply a mouthguard for your comfort. Please request one.
5. TMS could theoretically induce transient changes in cognition or movement, although safety studies have not found such side effects to date.

Psychotropic medications in general slightly increase a person's rate of seizures, independent of TMS. There is no connection between these medications and seizing during TMS, as many have been used without incident, however changing these medications need to be discussed with the TMS team and noted by the psychiatrist. Withdrawal from some medications can increase risk for seizures, so Duluth & St. Cloud TMS would redetermine the motor threshold and adjust the stimulus intensity if medications were adjusted.

Alcohol and drug use can have a strong impact on the risk of seizures during TMS treatment. Do not drink alcohol prior to treatment, and do not increase your overall alcohol intake while receiving therapy. Patients who come in smelling of alcohol will be asked to reschedule when it is safe for them to receive treatment. The use of cannabis is not contraindicated for TMS; however, other drugs should be avoided during treatment.

Sleep deprivation has long been identified as a trigger for a seizure. Sleep changes must be discussed with the TMS technician. TMS stimulates the brain, and if you are extremely tired, this can cause adverse effects. Focus on good sleep hygiene while you are receiving TMS therapy.

To date there is only one absolute contradiction for repetitive TMS - the presence of ferromagnetic substance in the head. Ferromagnetic means a substance that is highly susceptible to magnetization. We do not know about the long-term consequences of TMS, since it was only FDA approved for depression in 2008. It is strongly recommended not to interrupt your treatment during the acute phase.

I understand that Duluth & St. Cloud TMS will not compensate me for injuries that may or may not have occurred from an adverse reaction to TMS. Reasonable medical treatment will be offered for injuries directly caused by my TMS treatment, for which the insurer or I will be billed at the usual fee. I release Duluth/St. Cloud TMS and all the providers and technicians from all liabilities and expenses related to my decision to receive TMS as part of my care.

I understand that I have the option to obtain treatment elsewhere and will be provided with a referral letter if needed.

I am aware there may be unexpected complications.

I am aware that the risks of exposure to a magnetic field during pregnancy are not fully understood.