Dakota County Chemical Health – Rule 25 Assessor Check List
Fax: 651.554.6349 or email [email protected]
Client Name:_______________________________
Date of Assessment:__________________
I have provided client with the following information:
AIDS Facts Brochure, Minnesota Department of Health – client keeps copy
Dakota County Social Services, Adult Services Brochure, Dakota County – client keeps copy
Health Care Coverage for Families, Medical Assistance and Minnesota Care, Minnesota Department of Human
Services - client keeps copy
Your Privacy Rights (Tennessen Notice): – client keeps one copy, one signed copy sent to Dakota County Social
Services (DAK 2519.01)
Chemical Use Assessment: Notice of Appeal Rights – client keeps one copy, one signed copy sent to Dakota County
Social Services
Dakota County Health Care Components Notice of Privacy Practices – client keeps copy
Acknowledgement of Receipt of Dakota County Health Care Components Notice of Privacy Practices – offer client a
signed copy, one signed copy sent to Dakota County Social Services
Application for Social Services, Minnesota Department of Human Services – offer client a signed copy, one signed
copy sent to Dakota County Social Services
Release of Information –offer client a signed copy, one signed copy sent to Dakota County Social Services
ROIs for two Rule 25 Collateral Contacts (DAK 4582)
For any Dakota ROI signed, program needs to have one from their own program’s ROI signed as well.
Please ask that an ROI be completed for Rule 31 clinics.
Client Checklist Indicating Client has Received Tennessen Warning, HIPAA, Appeal Rights and copies of any/all ROIs
that they signed - offer client a signed copy, one signed copy sent to Dakota County Social Services
Client Placement Authorization (CPA), fill in boxes 4-30 and have client sign.
Rule 25 Assessment completed in full – send to Dakota County Social Services
Rule 25 Placement Summary (DHS Handout 4A-3) – circle severity ratings, do not add any narrative in the boxes –
send to Dakota County Social Services
DAK3304 (6/2016)
Chemical Health Services
Rule 25 Eligibility Application
Important: Tennessen Notice must be signed and dated
prior to completion of the eligibility application!
YOUR PRIVACY RIGHTS
(Tennessen Notice)
Information about your rights under the Minnesota Data Practices Act
The Minnesota Government Data Practices Act, Minn. Statute Chapter 13, (hereinafter “Data Practices Act) seeks to
protect the privacy of the individuals about whom government agencies, their subdivisions, and agencies under contract
with them collect data. The Minnesota Government Data Practices Act also facilitates the release of information that is
public. The information on this sheet applies to your current and future contacts with this agency, whether the contact is
in person, by mail or by phone.
The Data Practices Act requires that whenever we ask you to provide us with private or confidential information about
yourself that you be told:




The purpose and intended use of the data within this agency;
The legal requirements, if any, of providing the information;
The consequences of providing or refusing to provide the information requested; and
The identity of other persons or agencies authorized by statute to receive the information.
Purposes
The purposes of the information we collect from you are listed below. Because this list of purposes covers a variety of
programs, some of the purposes listed may not apply to you. Details about the purposes of the information we collect
from you are often listed on the forms you are asked to complete. Depending upon the program you are in, the data we
collect from you may be used for the following purposes:













To comply with any court ordered treatment
Determine your eligibility for assistance or services provided by this agency
Provide effective care and treatment of medical/social/psychological problems
Establish the amount of financial aid for which you are eligible
Enable us to collect federal, state or county funds for assistance and services for you or your family
Determine your ability to pay for medical treatment or other assistance and services provided to you or to other
persons for whom you are responsible
Collect reimbursement from other agencies or individuals for services or assistance we give you
Obtain school assistance authorized by law
Investigate complaints or reports of abuse, maltreatment, neglect, fraud or misconduct
Investigate facility complaints
Ascertain applicant’s eligibility for adoption services
Conduct program and financial audits
Determine whether you or your children need protective services
During the time we will be involved with you, we will be asking you for information about your physical health, your mental
and emotional health, your chemical use, your living situation and employment, your finances, and/or your relationships.
We will only ask for information that we are authorized by law to have and that will help us provide you with appropriate
services.
Consequences of Providing or Not Providing Information
In most cases you are not legally required to provide the information requested. If you are legally required to supply the
information requested, you will be informed of the law that requires it. If you do not provide the information requested, we
may not be able to determine your eligibility for the services or assistance you request. In some cases giving you the
assistance or services will be delayed or otherwise hindered if you refuse to provide the information. Providing the
requested information will facilitate receiving the services available to you.
Minors
If you are a minor, you have the right to request that private data about you be kept from your parents. You must make
this request in writing. You must explain why you wish this data to be withheld and what you expect the consequences of
sharing the data with your parents would be. If the agency agrees that withholding the information from your parents is in
your best interests, the data will not be shown to your parents.
Sharing Information
There are other agencies that we are allowed by law to share information with if they need it for investigations, for
background studies, for licensing actions, or to help you or help us to help you. Information will only be shared with those
entities or organizations and anyone under contract with these entities or organizations once it is determined they need
the information to perform their jobs. These may include:
 Services providers under contract with Dakota County
to provide Rule 25 chemical dependency assessment
services
 Service providers under contract with Dakota County
to provide Rule 31 chemical dependency treatment
services
 US Department of Health and Human Services
 Social Security Administration
 Minnesota Department of Human Services
 Minnesota Department of Health
 Local and State Law Enforcement
 Coroner or Medical Examiner
 County Attorney or Attorney General
 Internal Revenue Service
 Multidisciplinary Case Consultation Teams
 Minnesota Department of Revenue
 Other County Welfare or Human Services Agencies
 Court Officials
 Ombudsman for Mental Health & Mental Retardation.
 Local Early Childhood Intervention Contacts
 Applicable school districts and service providers
 The Immigration and Naturalization Service
 Managed care organizations about your health care or
benefits
 Insurance companies to check health care benefits for
you or your family members
 Employees or volunteers of any welfare agency who
need the information to do their jobs
 Community Mental Health boards, state hospitals,
state nursing homes, and/or entities under contract to
one of these facilities, to the extent of the contract.
 The Dakota County Public Health Department, the
Community Corrections Department, the Employment
and Economic Assistance Department, and the Social
Services Department
 Any other government agency that is authorized to
have the information under state or federal law and
has a need to know about the information
 Other: ______________________
Other Rights






You have the right to know what information is maintained about you.
You have the right to view all public and private information about you maintained by this agency. This includes the
right for you to authorize other persons or agencies to view it.
You have the right to have data to which you have access explained to you.
You have the right to request copies of the information to which you have access. You may, however, be required to
pay for the cost of those copies.
You have the right to challenge the accuracy or completeness of any private information in your records. If you want
to challenge any information, write to the responsible authority of the agency that has your records. You may also talk
to the person at this agency who works with you.
You have the right to insert your own explanation of anything you object to in your records.
I acknowledge I have received this Notice that explains my privacy rights. If I have any questions or
concerns, I can contact Dakota County Social Services at 651-554-6000.
Client Signature
Date
Copy Provided / Initials
Chemical Health Services
Rule 25 Eligibility Application
Important: Tennessen Notice must be signed and dated
prior to completion of the eligibility application!
YOUR PRIVACY RIGHTS
(Tennessen Notice)
Information about your rights under the Minnesota Data Practices Act
The Minnesota Government Data Practices Act, Minn. Statute Chapter 13, (hereinafter “Data Practices Act) seeks to
protect the privacy of the individuals about whom government agencies, their subdivisions, and agencies under contract
with them collect data. The Minnesota Government Data Practices Act also facilitates the release of information that is
public. The information on this sheet applies to your current and future contacts with this agency, whether the contact is
in person, by mail or by phone.
The Data Practices Act requires that whenever we ask you to provide us with private or confidential information about
yourself that you be told:




The purpose and intended use of the data within this agency;
The legal requirements, if any, of providing the information;
The consequences of providing or refusing to provide the information requested; and
The identity of other persons or agencies authorized by statute to receive the information.
Purposes
The purposes of the information we collect from you are listed below. Because this list of purposes covers a variety of
programs, some of the purposes listed may not apply to you. Details about the purposes of the information we collect
from you are often listed on the forms you are asked to complete. Depending upon the program you are in, the data we
collect from you may be used for the following purposes:













To comply with any court ordered treatment
Determine your eligibility for assistance or services provided by this agency
Provide effective care and treatment of medical/social/psychological problems
Establish the amount of financial aid for which you are eligible
Enable us to collect federal, state or county funds for assistance and services for you or your family
Determine your ability to pay for medical treatment or other assistance and services provided to you or to other
persons for whom you are responsible
Collect reimbursement from other agencies or individuals for services or assistance we give you
Obtain school assistance authorized by law
Investigate complaints or reports of abuse, maltreatment, neglect, fraud or misconduct
Investigate facility complaints
Ascertain applicant’s eligibility for adoption services
Conduct program and financial audits
Determine whether you or your children need protective services
During the time we will be involved with you, we will be asking you for information about your physical health, your mental
and emotional health, your chemical use, your living situation and employment, your finances, and/or your relationships.
We will only ask for information that we are authorized by law to have and that will help us provide you with appropriate
services.
Consequences of Providing or Not Providing Information
In most cases you are not legally required to provide the information requested. If you are legally required to supply the
information requested, you will be informed of the law that requires it. If you do not provide the information requested, we
may not be able to determine your eligibility for the services or assistance you request. In some cases giving you the
assistance or services will be delayed or otherwise hindered if you refuse to provide the information. Providing the
requested information will facilitate receiving the services available to you.
Minors
If you are a minor, you have the right to request that private data about you be kept from your parents. You must make
this request in writing. You must explain why you wish this data to be withheld and what you expect the consequences of
sharing the data with your parents would be. If the agency agrees that withholding the information from your parents is in
your best interests, the data will not be shown to your parents.
Sharing Information
There are other agencies that we are allowed by law to share information with if they need it for investigations, for
background studies, for licensing actions, or to help you or help us to help you. Information will only be shared with those
entities or organizations and anyone under contract with these entities or organizations once it is determined they need
the information to perform their jobs. These may include:
 Services providers under contract with Dakota County
to provide Rule 25 chemical dependency assessment
services
 Service providers under contract with Dakota County
to provide Rule 31 chemical dependency treatment
services
 US Department of Health and Human Services
 Social Security Administration
 Minnesota Department of Human Services
 Minnesota Department of Health
 Local and State Law Enforcement
 Coroner or Medical Examiner
 County Attorney or Attorney General
 Internal Revenue Service
 Multidisciplinary Case Consultation Teams
 Minnesota Department of Revenue
 Other County Welfare or Human Services Agencies
 Court Officials
 Ombudsman for Mental Health & Mental Retardation.
 Local Early Childhood Intervention Contacts
 Applicable school districts and service providers
 The Immigration and Naturalization Service
 Managed care organizations about your health care or
benefits
 Insurance companies to check health care benefits for
you or your family members
 Employees or volunteers of any welfare agency who
need the information to do their jobs
 Community Mental Health boards, state hospitals,
state nursing homes, and/or entities under contract to
one of these facilities, to the extent of the contract.
 The Dakota County Public Health Department, the
Community Corrections Department, the Employment
and Economic Assistance Department, and the Social
Services Department
 Any other government agency that is authorized to
have the information under state or federal law and
has a need to know about the information
 Other: ______________________
Other Rights






You have the right to know what information is maintained about you.
You have the right to view all public and private information about you maintained by this agency. This includes the
right for you to authorize other persons or agencies to view it.
You have the right to have data to which you have access explained to you.
You have the right to request copies of the information to which you have access. You may, however, be required to
pay for the cost of those copies.
You have the right to challenge the accuracy or completeness of any private information in your records. If you want
to challenge any information, write to the responsible authority of the agency that has your records. You may also talk
to the person at this agency who works with you.
You have the right to insert your own explanation of anything you object to in your records.
I acknowledge I have received this Notice that explains my privacy rights. If I have any questions or
concerns, I can contact Dakota County Social Services at 651-554-6000.
Client Signature
Date
Copy Provided / Initials
Dakota County
Social Services
Dakota County Social
Services wants to make
sure that you have the best
possible service experience
and that these service
expectations are met.
Should these expectations
not be met, please contact
your social worker’s
supervisor or the deputy
director by calling
Adult Services
Vulnerable Adult
Mental Health
Chemical Health
651-554-6000
Dakota County Social Services
Northern Service Center
1 Mendota Road
West St. Paul, MN 55118
651-554-6000
Client Service
Expectations
and
Responsibilities
To our client,
Social Services commits to meeting
these service expectations:
You can expect good personal
service.
Your social worker will:
•
Make initial contact with you within 3
working days and within 5 working
days meet face-to-face with you
•
Return all phone calls within 24 hours
•
Make contact with you in accordance
with your individual case plan
•
Treat you with respect
•
Connect you to your social worker’s
supervisor for conflict resolution
You can expect a clear plan for
addressing your needs.
Your social worker will:
•
Work with you to develop a family or
individual service plan within 30 days of
your face-to-face visit
•
Review your plan with you at least
twice a year
•
Assist you with solving problems and
carrying out solutions
You can expect county services will
be easy to understand and use.
Your Responsibilities as a
Social Services Client
Be Responsive
•
Keep appointments and if you cannot
keep an appointment, notify your social
worker at least 24 hours prior to the
scheduled appointment
•
Ask questions when you don’t
understand the information you receive
or what you are told by your social
worker
•
Treat your social worker with respect
Your social worker will:
•
Give you complete information about
service eligibility, confidentiality policies,
and potential fees for services
•
Tell you about available services that
match your individual or family’s needs
•
Explain why a service is recommended
and what alternatives are available
•
Inform you of your right to appeal and
give you the forms for filing an appeal if
you are unhappy with a service
decision, written material or an agency
determination
Provide complete information
•
Provide complete and accurate
information about past and present
circumstances relating to your needs
and concerns
•
Inform your social worker of any
changes in your circumstances relating
to your needs and concerns
OPPORTUNISTIC DISEASES
HIV TESTING
People with advanced HIV disease or AIDS
are vulnerable to infections and cancers
called 'opportunistic infections' because
they occur when one’s immune system is
weakened. Examples include bacterial
pneumonia, tuberculosis, cervical cancer,
Kaposi's sarcoma, candidiasis (thrush),
mycobacterial infections, taxoplasmosis,
and cryptosporidiosis to name a few.
As with many other diseases there is no
single test for diagnosing AIDS. There is
a test for detecting antibody to HIV, the
virus that causes AIDS. Presence of
antibody means that a person is infected
with HIV and is capable of spreading it.
However, recent antiretroviral therapies are
keeping one’s immune system healthier
and help prevent opportunistic infections
from occurring. Measures to treat these
infections directly become essential if
antiretrovirals stop working due to poor
adherence, drug resistance or other factors.
Managing and preventing opportunistic
infections not only helps HIV-positive
people to live longer, healthier lives, but
can also help prevent transmissible
opportunistic infections from spreading to
others.
TREATMENT
Currently, there are no drugs or vaccines
available to cure AIDS or prevent HIV
infection, although the search for such a
drug or vaccine continues. Studies are
currently underway to see if antiviral drugs
can prevent HIV infection when taken
regularly by uninfected persons.
For those living with HIV, no treatment has
yet been successful in fully restoring the
immune system. However, combination
therapies have helped to combat the virus and
restore the immune system to a healthier level.
The earlier a patient gets tested and treated,
the more effective these treatments become.
Lower viral loads through treatment have
been shown to reduce transmission risk.
For people who think they are infected
with HIV, the HIV antibody test is
available through private physicians,
family planning clinics, STD/STI clinics,
or at HIV counseling and testing sites.
These publicly funded sites provide free,
confidential counseling and HIV antibody
testing. Clinic staff are trained to answer
questions about AIDS and to provide
medical and mental health referrals.
 Crown Medical Center
Minneapolis, (612) 871-4354
 Face to Face Health and Counseling
Service, Inc.
St. Paul, (651) 772-5555
 Hennepin County Public Health
Clinic - Red Door Services
Minneapolis, (612) 543-5555
 North Memorial Broadway Family
Medicine
Minneapolis, (612) 302-8200
 Clinic 555, St. Paul-Ramsey County
Department of Public Health St. Paul,
(651) 266-1255
 West Side Community Health
Services
St. Paul, (651) 222-1816
There are over 30 other HIV testing sites
throughout Minnesota. Contact the
Minnesota AIDS Project (MAP)
AIDSLine (number listed on next panel)
for the nearest location to you.
FOR MORE INFORMATION
Minnesota AIDS Project AIDSLine
Metro Area
(612) 373-AIDS
(612) 373-2465 TTY
Statewide
(800) 248-AIDS
(888) 820-2437 TTY
http://www.mnaidsproject.org
Infectious Disease Epidemiology, Prevention
and Control Division
STD and HIV Section
(651) 201-5414
http://www.health.state.mn.us/hiv
For more information about Sexually
Transmitted Diseases/Infections
(STDs/STIs), call the Minnesota Family
Planning and STD Hotline:
1-800-78-FACTS voice/TTY
(Telecommunications devices for the deaf)
(651) 645-9360 (Metro area)
http://www.sexualhealthmn.org
AIDSfacts
Acquired Immunodeficiency Syndrome, or
AIDS, was first reported in the United States
in mid-1981. Since that time, the Centers for
Disease Control and Prevention (CDC)
estimates that 1.2 million Americans are
living with HIV and about one fifth are
unaware of their HIV infection.
Through 2012 in Minnesota 10,112 HIV and
AIDS cases have been reported including
3,947 that have died. There are an estimated
7,516 people who are aware of their HIV
status and currently living in Minnesota.
This brochure provides accurate information
about AIDS, the risk of getting HIV
infection and ways to prevent the infection
from occurring.
Minnesota Department of Health
Infectious Disease Epidemiology, Prevention and
Control Division
STD and HIV Section
Freeman Office Building
Post Office Box 64975
St. Paul, MN 55164-0975
To order brochures in another format,
such as large print, Braille, or cassette
tape, call (651) 201-5414
07/13
Infectious Disease Epidemiology, Prevention and Control Division
STD and HIV Section
BASICS ABOUT AIDS
The term “AIDS” stands for acquired
immunodeficiency syndrome. People who
have AIDS have a defect in natural
immunity against disease. People who have
AIDS can get serious illnesses that would
not be a threat to anyone whose immune
system was functioning normally. These
illnesses are referred to as “opportunistic”
infections or diseases.
CAUSE
AIDS is caused by the human
immunodeficiency virus (HIV). This virus
infects certain cells of the immune system,
and can also directly infect the central
nervous system and brain. Infection with
HIV may not always lead to AIDS. Some
infected persons remain in good health for
years. Others develop illness varying in
severity from mild to extremely serious.
THE SPREAD OF HIV
HIV is found in blood, semen, vaginal
secretions and other body fluids of a person
who is infected with HIV.
HIV is spread by sexual contact, needle
sharing, or rarely, through transfused blood
or its components. HIV may also be
transmitted from an infected mother to
infant during pregnancy, birth, or through
breast feeding. The risk of infection with
HIV is increased by:
 Having vaginal or anal sex without a latex
condom.
 Having oral sex without a latex condom
or other latex barrier.
 Sharing needles or equipment to inject
drugs, body pierce or tattoo.
 Having sex with more than one partner.
HIV IS NOT SPREAD BY
CASUAL CONTACT
 Not allowing blood, semen, and vaginal
secretions from your partner to enter
your mouth, vagina, or anus.
Casual contact with HIV infected persons
does not place others at risk for getting the
illness. Although a few cases have been
found where HIV has been transmitted in
household settings, the situations have
involved blood contact. There is no risk
of getting HIV from daily contact at work,
school, or at home. In general, infants
with AIDS or HIV infection have not
transmitted the infection to family
members living in the same household.
Nurses, doctors, and health care personnel
are at very low risk for acquiring HIV
even when directly caring for AIDS
patients.
 Latex condoms, when used consistently
and correctly, are highly effective in
preventing the transmission of HIV.
They should always be used during oral,
vaginal, and anal sex. Polyurethane
condoms are now available for those
with latex allergies.
HIV infection cannot be spread by:
 Shaking Hands
 Hugging
 Coughing
 Sneezing
 A social kiss
 Swimming pool






Toilet seat
Food
Insects
Animals
Cups
Air
PREVENTION
HIV infection is preventable and knowing
your HIV status is always important since
symptoms may not appear for years. If
you avoid sexual contact or don’t share
needles, you can eliminate your risk. If
you chose to have oral, anal, or vaginal
sex, you can reduce your sexual risk by:
 Not having sex with more than one
partner or with men or women who do.
The more partners you have the greater
your chance of becoming infected.
 Avoiding sex with persons who are
known to be infected with HIV and
those who share needles or equipment to
inject drugs, tattoo, or body pierce.
 Using water-based lubricants to prevent
tears in skin or condoms during sex. Do
not use petroleum jelly or other oilbased lubricants with latex condoms.
 Using the female condom (polyurethane
pouch that is inserted into the vagina).
This may offer another option instead of
a male worn condom.

If infected with HIV, get into treatment
as lower viral loads have shown to
reduce the risk of transmission.

A prescription antiviral drug is now
available for high risk persons to take
daily (pre-exposure prophylaxis or
PrEP) to help reduce their risk of
infection.
If you use injectable drugs:
 Do not share needles, cookers, or cotton
when injecting drugs. In the U.S., about
16% of all persons living with HIV are
related to injection drug use.
 In Minnesota to help prevent the sharing
of needles, persons are allowed to buy
up to 10 new syringes/needles without a
prescription at certain pharmacies. Visit
the MDH web site listed on the back of
this brochure for pharmacy locations.
Health Care Workers:
Health care and laboratory workers should
follow standard safety procedures
carefully when handling any blood,
needles and tissue samples from patients.
SIGNS AND SYMPTOMS
Most individuals infected with HIV have no
symptoms and feel well. Some develop
symptoms that may include tiredness, fever,
loss of appetite and weight, diarrhea, night
sweats, and swollen glands (lymph nodes) –
usually in the neck, armpits, or groin.
Anyone who has these symptoms for more
than two weeks should see a doctor. The
time between infection with the virus and the
onset of symptoms of AIDS ranges from a
few months to 10 years or more. Infected
persons can still spread the virus even though
they don’t have symptoms.
DIAGNOSIS
Certain tests that show damage to various
parts of the immune system, the presence of
opportunistic diseases, plus laboratory
evidence of HIV all assist in making the
diagnosis of AIDS. HIV-infected persons
are considered to have AIDS when certain
opportunistic diseases are present or when
their blood levels of certain immune cells
drop below a certain point.
DONATING BLOOD
In the U.S., it is impossible for a donor to get
HIV from giving blood or plasma. Blood
banks and other blood collection centers use
sterile equipment and disposable needles.
Each needle is brand new and used only
once, then destroyed. The need for blood is
great, and people who are not at increased
risk from getting HIV are urged to continue
to donate blood as they have in the past.
All donated blood has been tested for HIV
antibody since March 1985 and for HIV viral
particles (referred to as P24 antigen) since
March 1996. Blood identified with HIV
antibody or antigen is not used for
transfusions.
Minnesota Health Care Programs
Minnesota Department of Human Services
DHS-3182-ENG
Minnesota Health Care
Programs
Minnesota Health Care Programs can give you and your
family coverage for most medical services or provide help
paying your Medicare premiums, deductibles and copays.
How much help you can get depends on the program you
qualify for.
Medical Assistance
Medical Assistance (MA) is Minnesota’s Medicaid
program. There is no monthly cost to enrollees. MA pays
for current and future medical bills. MA may also pay
medical bills going back three months from when we get
your application.
You can have other health insurance and still qualify. MA
may help pay for the cost of your other health insurance.
Medical Assistance for
Employed Persons with
Disabilities (MA‑EPD)
MA-EPD gives employed persons with disabilities MA
coverage when their income is more than the MA income
limit. You must be certified disabled and earn more than
$65 a month. An asset limit of $20,000 applies. Assets
owned by your spouse do not count. You pay a monthly
premium based on your income. American Indians usually
do not pay a premium.
Medicare Savings Programs
Medicare Savings Programs can help pay Medicare
premiums, deductibles and copays for people enrolled or
who can enroll in Medicare.
MinnesotaCare
MinnesotaCare is a Minnesota health care program.
MinnesotaCare is low-cost health care coverage for
Minnesotans who do not qualify for MA or Medicare,
or cannot get affordable insurance through an employer.
Most people pay a monthly premium. The premium is
based on your household size and income. Coverage starts
the first day of the month after you pay your premium.
What services are covered?
MA, MA-EPD and MinnesotaCare covered services
include:
Doctor’s visits
Outpatient care
Emergency care
Hospital care
Maternity and newborn care
Mental health care
Alcohol and drug treatment
Prescription drugs
Rehabilitative services
Laboratory services
Preventive and wellness care
Chronic disease management
Dental care
Vision care including eye glasses
Chiropractic care
Family planning
Hearing aids
Medical equipment and supplies
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
Over 
1-17
You may have to pay a copay for some medical services.
Pregnant women and children under 21 do not pay
copays.
The Medicare Savings Programs help pay Medicare
related costs.
■■
■■
■■
■■
Qualified Medicare Beneficiary (QMB) pays
Medicare premiums, deductibles, copays and
coinsurance (DHS-2087E)
Service Limited Medicare Beneficiary (SLMB) pays
Medicare Part B premiums (DHS-2087G)
Qualified Individual (QI) pays Medicare Part B
premiums for higher income individuals (DHS-2087I)
Qualified Working Disabled (QWD) pays Medicare
Part A premiums if you cannot get free Medicare Part
A (DHS-2087F)
How can I qualify?
You must meet program rules including income limits.
How much income you can have and still qualify
depends on your household size, age, pregnancy status,
if you are blind or have a disability, and the health care
program you qualify for. NOTE: Income guidelines
are approximations only. Use these charts for general
reference.
MA Monthly Income Limits
effective 7-1-16 – 6-30-17
Family size
Infants under 2
1
Parents and
caretaker
relatives
$981
$3,715 $4,679
$963
If your income is more than the income limits, you
may still qualify for MA by meeting a spenddown. A
spenddown is like an insurance deductible. You pay part
of your medical bills and MA pays the rest.
I am pregnant. If I qualify, will my
baby get health care?
If you get MA as a pregnant woman, your baby will
get MA through the month of his or her first birthday.
During the first year, your baby’s coverage cannot stop if
he or she continues to live in Minnesota.
MA Asset Limits
Assets are items you own. Assets that may count include
cash, bank accounts, stocks, bonds, certain vehicles
and property where you do not live. Assets that do not
count include the home where you live, household goods,
personal items such as clothing and jewelry, and certain
assets owned by an American Indian.
There is no asset limit if you qualify as a pregnant woman,
a parent or caretaker relative of a child under age 19, a
child under age 21, or an adult under age 65 without
children. Parents and caretaker relatives who qualify for
MA with a spenddown have an asset limit of $20,000.
The asset limit if you qualify as a person who is blind,
has a disability or is age 65 or older is $3,000 for one and
$6,000 for a household of two or more.
Medicare Savings Programs Monthly
Income Limits effective 7-1-16 – 6-30-17
1
2
For each
additional
person, add
Qualified Medicare
Beneficiary (QMB)
$1,010
$1,357
$347
Service Limited
Medicare Beneficiary
(SLMB)
$1,208
$1,624
$416
Family size
$2,722
$1,316
Adults age 19
-64 without
children
$1,316
Adults age 65
and older
$990
People who
are blind
or have a
disability
$4,763
2
$2,801 $3,782
Pregnant
Women*
Children 2
through 18
3
For each
additional
person, add
Can I qualify if my income is more
than these limits?
$990
$3,675 $4,629
$1,777 $2,238
$953
$461
$1,777 $2,238
$461
Qualified Individual
(QI)
$1,357
$1,825
$468
$1,337
$347
Qualified Working
Disabled (QWD)
$2,000
$2,694
$694
$1,337
$1,684
$1,684
*A pregnant woman counts as two or more.
$347
The asset limit is $10,000 for a single person and $18,000
for a family of two or more, except for QWD. The QWD
asset limit is $4,000 for a single person and $6,000 for a
family of two or more.
MinnesotaCare Yearly Income Limits
effective 1-1-17 – 12-31-17
Family Size
Income limit
1
$23,760
2
$32,040
3
$40,320
For each additional person, add
$8,320
There is no asset limit for MinnesotaCare.
What if I do not qualify for a
Minnesota Health Care Program
but still need coverage?
You may be able to get health care coverage through your
work. Ask your employer if they offer health insurance
to you and your family. If your employer does not offer
affordable health insurance, you may qualify for a tax
credit to help you buy health insurance.
Qualified Health Plans (QHP)
and MNsure
You may be able to buy Qualified Health Plan (QHP)
coverage, with or without a tax credit on MNsure. If you
qualify for a tax credit, the tax credit can help pay the
monthly premium.
MNsure is Minnesota’s health insurance marketplace.
You can find, compare, and choose, quality health care
coverage that best fits your needs and budget. QHPs are
commercial health insurance plans offered by insurance
companies. All plans offer preventive services, mental
health and substance abuse services, emergency services,
prescription drugs and hospitalization. Some plans include
more benefits.
Each plan is reviewed by state regulators, certified as a
QHP and approved to be sold on MNsure.
You are able to enroll in a QHP during the open
enrollment period of November 15, 2014 through
February 15, 2015. You may qualify to enroll at other
times due to certain life events such as the birth of a child,
marriage or loss of health insurance coverage.
Advance Premium Tax Credit
The Advanced Premium Tax Credit allows you to get a
federal tax credit right away to pay a part of your QHP
premium. To qualify you must file taxes at the end of the
year and enroll in a QHP through MNsure. The tax credit
is paid to the health plan you choose. You must pay your
portion of the health care premium to the health plan to
start and keep coverage.
You may also qualify for cost sharing reduction. This
benefit lowers the copays, coinsurance, and out-of-pocket
costs you pay for health care services.
How can I apply?
Most people can apply for all Minnesota Health Care
Programs:
Online at www.mnsure.org
By filling out the paper Application for Health
Coverage and Help Paying Costs (DHS-6696).
Go to http://mn.gov/dhs/general-public/publicationsforms-resources/application-forms/index.jsp or call
your local county agency to get the application.
■■
■■
The people listed below should apply for Medical
Assistance (MA) by filling out the Minnesota Health
Care Programs Application for Certain Populations
(DHS‑3876). Use this application if you:
Are a child in foster care.
Are 65 years of age or older.
Receive Supplemental Security Income (SSI).
Only want to apply for a Medicare Savings Program.
Are applying for Medical Assistance for Employed
Persons with Disabilities (MA-EPD).
■■
■■
■■
■■
■■
Go to http://mn.gov/dhs/general-public/publicationsforms-resources/application-forms/index.jsp or call your
local county agency to get the application.
If you want to apply for payment of long-term care services
such as nursing home care or services to help you stay in
your home, apply:
By filling out the Minnesota Health Care
Programs Application for Payment of Long-Term
Care Services paper application (DHS-3531). Go to
http://mn.gov/dhs/general-public/publications-formsresources/application-forms/index.jsp or call your
local county agency to get the application.
■■
Can I get help filling out the
application?
You can get help filling out either the online or paper
application by:
Calling 1-855-366-7873.
Contacting an assister in your area. Visit
www.mnsure.org or call 1-855-366-7873
for an assister network list.
Calling your local county agency.
■■
■■
■■
Attention. If you need free help interpreting this document, ask your worker or call the number below for
your language.
ያስተውሉ፡ ይህንን ዶኩመንት ለመተርጎም እርዳታ የሚፈልጉ ከሆነ፡ የጉዳዮን ሰራተኛ ይጠይቁ ወይም በሰልክ ቁጥር 1-844-217-3547
ይደውሉ።
.1-800-358-0377 ‫ اطلب ذلك من مشرفك أو اتصل على الرقم‬،‫ إذا أردت مساعدة مجانية لترجمة هذه الوثيقة‬:‫مالحظة‬
သတိ။ ဤစာရြက္စာတမ္းအားအခမဲ့ဘာသာျပန္ေပးျခင္း အကူအညီလုိအပ္ပါက၊ သင့္လူမွဳေရးအလုုပ္သမား အားေမးျမန္း ျခင္းသုုိ ့မဟုုတ္
1-844-217-3563 ကုုိေခၚဆုုိပါ။
kMNt’sMKal’ . ebIG~k¨tUvkarCMnYyk~¬gkarbkE¨bäksarenHeday²tKit«f sUmsYrG~kkan’sMNuMerOg rbs’G~k ÉehATUrs&BÍmklex
1-888-468-3787 .
請注意，如果您需要免費協助傳譯這份文件，請告訴您的工作人員或撥打 1-844-217-3564。
Attention. Si vous avez besoin d’une aide gratuite pour interpréter le présent document, demandez à votre
agent chargé du traitement de cas ou appelez le 1-844-217-3548.
Thov ua twb zoo nyeem. Yog hais tias koj xav tau kev pab txhais lus rau tsab ntaub ntawv no pub dawb,
ces nug koj tus neeg lis dej num los sis hu rau 1-888-486-8377.
ymol.ymo;b.wuh>I zJerh>vd.b.w>rRpXRuvDvXw>uusd;xH0J'.vHm wDvHmrDwcgtHRM.<oHuG>b.ySR*h>0DtySRrRpXRw>vXe*D>rhw
rh>ud;b. 1-844-217-3549 wuh>I
알려드립니다. 이 문서에 대한 이해를 돕기 위해 무료로 제공되는 도움을 받으시려면 담당자에게
문의하시거나 1-844-217-3565으로 연락하십시오.
້ ຣີ, ຈງ່ ົ ຖາມພະນ ັກງານກາກ
ໂປຣດຊາບ. ຖາ້ ຫາກ ທາ່ ນຕອ
� ັບການຊວ
້ ງການການຊວ
່ ຍເຫຼືອໃນການແປເອກະສານນີຟ
່ ຍເຫຼືອ
ຂອງທາ່ ນ ຫຼື ໂທຣໄປທີ່ 1-888-487-8251.
Hubachiisa. Dokumentiin kun bilisa akka siif hiikamu gargaarsa hoo feete, hojjettoota kee gaafadhu ykn afaan
ati dubbattuuf bilbilli 1-888-234-3798.
Внимание: если вам нужна бесплатная помощь в устном переводе данного документа, обратитесь к
своему социальному работнику или позвоните по телефону 1-888-562-5877.
Digniin. Haddii aad u baahantahay caawimaad lacag-la’aan ah ee tarjumaadda qoraalkan, hawlwadeenkaaga
weydiiso ama wac lambarka 1-888-547-8829.
Atención. Si desea recibir asistencia gratuita para interpretar este documento, comuníquese con su trabajador
o llame al 1-888-428-3438.
LB1 (8-16)
Chú ý. Nếu quý vị cần được giúp đỡ dịch tài liệu này miễn phí, xin gọi nhân viên xã hội của quý vị hoặc
gọi số 1-888-554-8759.
For accessible formats of this publication or additional assistance with
equal access to human services, write to [email protected],
call 800-657-3739, or use your preferred relay service. (ADA1 [9-15])
CHEMICAL USE ASSESSMENT:
NOTICE OF APPEAL RIGHTS
I.
CLIENT RIGHT TO A SECOND ASSESSMENT
A. NOTICE. This agency is required to inform you of your rights to a second assessment. You have
the right to a second assessment if you do not agree with the assessment findings. The second
assessment must be provided in five working days. The second assessment must be provided by
a different assessor. This agency must tell you how to request the second assessment. If you
agree with the outcome of the second assessment, this agency shall place you in
accordance with placement criteria and the second assessment. If you disagree with the
outcome of the second assessment, this agency must place you according to the
assessment that is most consistent with your collatera l information.
B. TIMELINES. You must request a second assessment in writing or on a form approved by the
commissioner within five working days of the notification that your first assessment has been
completed or before the client enters treatment, whichever occurs first.
C. OUTCOME. If you agree with the second assessment, you must then be placed in that level of
care.
II. PLACEMENT APPEALS, RIGHT TO A FAIR HEARING
A. You have the right to a fair hearing. Fair hearings are handled by the Minnesota
Department of Human Services. This is separate from your right to a second assessment.
Your fair hearing request may be received by the local human services agency. You may
also request directly to the Minnesota Department of Human Services :
Appeals Unit
Minnesota Department of Human Services
444 Lafayette Road
St. Paul MN 55155
B. CAUSE FOR A FAIR HEARING. The rules allow for a fair hearing when an event listed below
occurs.
1.
2.
3.
4.
A request assessment is denied.
A requested second assessment is denied within the timelines.
A placement in treatment is denied, after an assessment has found that treatment is needed.
You disagree with the level or amount of care authorized by the placement agency, and
treatment has not yet begun.
5. You are receiving services that were authorized, and a request for additional services beyond
the length of the placement is denied.
6. You believe you are denied placement that is appropriate to your race, color, creed, disability,
national origin, religious preference, marital status, sexual orientation, or sex.
7. You were placed with a faith based treatment provider, you objected, and you were not given
an alternate referral.
C. FORM OF REQUEST FOR A FAIR HEARING. No special forms are needed to request a fair
hearing. The fair hearing request should be in writing. The local agency is required to provide
assistance if you need help writing the fair hearing request. The fair hearing request should
include the following items.
1. State what the assessment or placement agency did that you believe was wrong.
2. State any facts you believe are related to the issue.
3. State the relief you are seeking.
CH-DAK-4004 (04/2011)
D. EFFECT OF AN APPEAL. You do not lose any benefits you now receive if you request an
appeal. However, if you are in treatment and appeal the length or amount of services, the
treatment program will not be paid for care past the initial service period if the appeal is denied. If
your appeal is successful, the provider can receive payment for services that the appeal referee
agrees are needed. The treatment provider may not bill you for services provided while the
appeal is pending.
E. APPEAL CONSIDERATIONS. The appeals referee at the Minnesota Department of Human
Services rules on appeals. State rules guide the decisions of the referee. The referee must
consider whether your placement is similar to normal placements for the type of service you are
receiving. Secondly, the referee is authorized to consider your progress in the program. If you
have been making progress on program goals but have not completed the treatment plan, the
referee may authorize a longer period of treatment. Finally, the referee is authorized to consider
the aftercare plans the client and the local agency have available. If your additional needs can be
met after you leave the treatment program, the referee can deny the appeal.
SIGNATURE
CH-DAK-4004 (04/2011)
DATE
CHEMICAL USE ASSESSMENT:
NOTICE OF APPEAL RIGHTS
I.
CLIENT RIGHT TO A SECOND ASSESSMENT
A. NOTICE. This agency is required to inform you of your rights to a second assessment. You have
the right to a second assessment if you do not agree with the assessment findings. The second
assessment must be provided in five working days. The second assessment must be provided by
a different assessor. This agency must tell you how to request the second assessment. If you
agree with the outcome of the second assessment, this agency shall place you in
accordance with placement criteria and the second assessment. If you disagree with the
outcome of the second assessment, this agency must place you according to the
assessment that is most consistent with your collatera l information.
B. TIMELINES. You must request a second assessment in writing or on a form approved by the
commissioner within five working days of the notification that your first assessment has been
completed or before the client enters treatment, whichever occurs first.
C. OUTCOME. If you agree with the second assessment, you must then be placed in that level of
care.
II. PLACEMENT APPEALS, RIGHT TO A FAIR HEARING
A. You have the right to a fair hearing. Fair hearings are handled by the Minnesota
Department of Human Services. This is separate from your right to a second assessment.
Your fair hearing request may be received by the local human services agency. You may
also request directly to the Minnesota Department of Human Services :
Appeals Unit
Minnesota Department of Human Services
444 Lafayette Road
St. Paul MN 55155
B. CAUSE FOR A FAIR HEARING. The rules allow for a fair hearing when an event listed below
occurs.
1.
2.
3.
4.
A request assessment is denied.
A requested second assessment is denied within the timelines.
A placement in treatment is denied, after an assessment has found that treatment is needed.
You disagree with the level or amount of care authorized by the placement agency, and
treatment has not yet begun.
5. You are receiving services that were authorized, and a request for additional services beyond
the length of the placement is denied.
6. You believe you are denied placement that is appropriate to your race, color, creed, disability,
national origin, religious preference, marital status, sexual orientation, or sex.
7. You were placed with a faith based treatment provider, you objected, and you were not given
an alternate referral.
C. FORM OF REQUEST FOR A FAIR HEARING. No special forms are needed to request a fair
hearing. The fair hearing request should be in writing. The local agency is required to provide
assistance if you need help writing the fair hearing request. The fair hearing request should
include the following items.
1. State what the assessment or placement agency did that you believe was wrong.
2. State any facts you believe are related to the issue.
3. State the relief you are seeking.
CH-DAK-4004 (04/2011)
D. EFFECT OF AN APPEAL. You do not lose any benefits you now receive if you request an
appeal. However, if you are in treatment and appeal the length or amount of services, the
treatment program will not be paid for care past the initial service period if the appeal is denied. If
your appeal is successful, the provider can receive payment for services that the appeal referee
agrees are needed. The treatment provider may not bill you for services provided while the
appeal is pending.
E. APPEAL CONSIDERATIONS. The appeals referee at the Minnesota Department of Human
Services rules on appeals. State rules guide the decisions of the referee. The referee must
consider whether your placement is similar to normal placements for the type of service you are
receiving. Secondly, the referee is authorized to consider your progress in the program. If you
have been making progress on program goals but have not completed the treatment plan, the
referee may authorize a longer period of treatment. Finally, the referee is authorized to consider
the aftercare plans the client and the local agency have available. If your additional needs can be
met after you leave the treatment program, the referee can deny the appeal.
SIGNATURE
CH-DAK-4004 (04/2011)
DATE
DAKOTA COUNTY HEALTH CARE COMPONENTS
NOTICE OF PRIVACY PRACTICES
Effective April 14, 2003
Amended March 22, 2010
This notice describes how medical information and
other private information about you may be used
and disclosed and how you can get access to this
information. Please review it carefully.
Under the Minnesota Government Data Practices Act
and the Health Insurance Portability and Accountability
Act of 1996 (HIPAA), you have the right to privacy
regarding your Protected Health Information (PHI).
These laws protect your right to privacy regarding your
PHI, however these laws also allow Dakota County to
use and disclose information with others if required by
law. Under HIPAA, we are required to keep your PHI
private and give you a notice of our legal duties and
privacy practices to protect your protected health
information. We will limit the use and disclosure of PHI
to the minimum necessary to provide services and
benefits to you or to accomplish the intended purpose
of the use, disclosure, or request. Protected Health
Information is health information about you which can
be used to identify you and relates to your past,
present, or future physical or mental health condition(s),
related health care services, and payment. Dakota
County is required to abide by the terms of the notice
currently in effect.
However, we reserve the right to change the privacy
practices described in this notice, in accordance with
law. Changes to our privacy practices apply to all
health information we maintain as well as any
information we receive in the future. If Dakota County
changes its privacy practices, we will post the new
notice at each Dakota County site and facility and
provide it as required by law. You may ask for a copy
of the current notice anytime you visit a Dakota County
facility, or online at www.co.dakota.mn.us.
This Notice describes the privacy practices pertaining to
the use and disclosure of PHI that apply to the covered
health care components of Dakota County which
consist of the Social Services Department; the
Employment and Economic Assistance Department
(except Child Support); the Public Health Department
(except for Nursing Services provided to the Dakota
County Jail and for Disease Control); the Civil Division
of the County Attorney's Office; Financial Services;
Information Technology; the Dakota County Health
DCPHD-GN-965 (3/22/10)
Care Flexible Spending Account; and the Community
Services Administration Department.
8.
For Law Enforcement. We may disclose your
health information to law enforcement when
required by federal or state law. For example, a
law may require Dakota County staff to disclose
PHI to law enforcement in response to legal
proceedings or medical emergencies.
9.
For Abuse Reports and Investigations. If
Dakota County suspects abuse, neglect, or
domestic violence, we may disclose health
information about you as required or permitted by
law.
This Notice will be interpreted for you in other languages,
if requested.
Dakota County may use and disclose your Protected
Health Information without your Authorization:
1.
For Treatment. Dakota County may use or disclose
your health information with health care providers
such as doctors, nurses, therapists and social
workers who are involved in your health care. For
example, information may be shared with our staff or
providers outside our system to create or carry out a
plan for your treatment.
2.
For Payment. Dakota County may use or disclose
your health information to obtain payment for or to
pay for the health services you receive. For
example, Dakota County may provide PHI in order to
bill your health plan for health care provided to you.
3.
For Health Care Operations. Dakota County may
use or disclose your health information about you in
order to manage its programs and activities. For
example, Dakota County may use your PHI to review
the quality of the services you receive, to train
employees, or to call you by name in the waiting area
when Dakota County staff is ready to meet with you.
4.
For Appointments and other Health Information.
Unless you have instructed us not to, Dakota County
may send you reminders for medical care or
checkups. Dakota County may send you the
information about health services that may be of
interest to you.
5.
For Health Oversight Activities. Dakota County
may use or disclose your health information to staff
at Dakota County or to authorities outside Dakota
County for the purpose of inspection or investigation
of health care providers.
6.
For Public Health Activities. Dakota County may
use or disclose health information about you for
public health activities required or permitted by law.
This may include using your medical record to report
certain diseases, birth or death information, or
information related to child abuse or neglect.
7.
For Judicial and Administrative Proceedings. We
may disclose health information about you in
response to a court order or as otherwise authorized
by law. For example, a court order or law may
require Dakota County staff to share PHI with the
court and attorneys in a family court proceeding.
10. For Government Programs. Dakota County may
use and disclose PHI for public benefits under
other government programs as authorized by law.
11. For Reports to Coroner, Medical Examiners,
and Funeral Directors. Dakota County may
disclose your PHI to coroners, medical examiners,
and funeral directors as authorized by law. For
example, we may disclose PHI to a coroner or
medical examiner to identify an individual or to
determine the cause of death.
12. For Research. Dakota County may use and
disclose your PHI for research purposes as
authorized by law.
13. For Health and Safety Concerns. Dakota County
may disclose your PHI to law enforcement in order
to avoid a serious threat to the health and safety of
a person or the public.
14. For Workers Compensation. Dakota County may
disclose your PHI as authorized by law to Workers’
Compensation or similar programs.
15. For Specialized Government Functions. Dakota
County may disclose your PHI to government
agencies with special functions, such as veteran’s
activities, National Security and Intelligence
activities, Protection Services to the President, and
correctional institutions and other law enforcement
custodial situations as authorized by law.
16. For Individuals Involved in Your Care or
Payment for Your Care. Dakota County may
disclose your PHI to family or other persons you
identify as directly involved in your health care.
You may object to the sharing of this information.
17. Inmates. Dakota County may disclose PHI as
authorized by law to a correctional institution
having legal custody of you in order for the
institution to give you health care; for the health
and safety of you or others; or for the safety and
security of the institution.
18. When Requested by Law. Dakota County may
use or disclose PHI when required by federal or
state law.
section b below. You may make a request at any
time, either verbally or in writing that the restrictions
you have requested be terminated. Verbal requests
will be documented by Dakota County.
19. Parental Access. Minnesota law requires Dakota
County to disclose PHI to parents, guardians, and
persons acting in a similar legal status in most
situations. We will act consistent with Minnesota
law.
Other than the uses and disclosures described
above, Dakota County will not use or disclose your
PHI without your written authorization, unless
otherwise authorized by law.
b) Dakota County must comply with your request to
restrict the disclosure of your PHI if: the disclosure is
to a health plan for purposes of carrying out payment
or health care operations and the PHI pertains solely
to a health care item or service for which the health
care provider has been paid out-of-pocket in full.
5.
You have the following Privacy Rights regarding
your PHI:
1.
You have the right to inspect and obtain copies
of your records, unless the records are
psychotherapy notes, or the information has been
compiled in reasonable anticipation of, or for use
in, a civil, criminal, or administrative action or
proceeding. You must make the request in writing.
You will be charged a fee for copying costs.
2.
You have the right to request that we amend
the health information we maintain in your
medical or billing record. Your request must be
in writing and we may deny your request in certain
circumstances.
3.
You have the right to a List of Disclosures. You
have the right to ask for a list of disclosures of your
PHI made by Dakota County in the six year period
prior to the date of your disclosure request. You
must make the request in writing. This list will not
include the disclosures made for treatment,
payment or health care operations. This list will not
include information made directly to you or your
family. In addition, the list will not include
information that was sent pursuant to your
authorization or as otherwise authorized by law. If
you request a list more than once during a year, we
may charge you a fee for each subsequent
request.
4.
You have the right to revoke your authorization
to release PHI. If you sign an authorization
requesting Dakota County to use or disclose your
PHI, you may revoke that authorization at any time
by notifying Dakota County in writing. This
revocation will not apply to any PHI that was
disclosed prior to the County’s receipt of your written
notification.
6.
You have the right to choose how Dakota County
communicates with you. You have the right to ask
that Dakota County share information with you in a
certain way or in a certain place. For example, you
may ask Dakota County to send information to your
work address instead of your home address. You
must make this request in writing. You do not have
to explain the basis for your request.
7.
You have the right to file a complaint. You have
the right to file a complaint if you do not agree with
how Dakota County has used or disclosed PHI about
you.
8.
You have the right to receive a paper copy of this
notice at any time.
You may contact Dakota County to review, correct, or
limit your Protected Health Information (PHI).
You may contact the Dakota County Privacy Officer at the
address listed at the end of this notice to:
1.
2.
Ask to look at or copy your records.
Ask to limit how information about you is used or
disclosed.
Ask to cancel your authorization.
Ask to correct or change your records.
Ask for a list of the times Dakota County disclosed
protected health information about you.
You have the right to request limits on the uses
or disclosures of PHI.
3.
4.
5.
a) You have the right to ask that Dakota County
limit how your PHI is used or disclosed. You must
make the request in writing and tell Dakota County
what information you want to limit and to whom you
want the limits to apply. Dakota County is not
required to agree to the restriction, except as
otherwise authorized by law and as stated in
Dakota County may deny your request to look at, copy or
change your records. If Dakota County denies your
request, we will send you a letter that tells you why your
request is being denied and how you can ask for a review
of the denial. You will also receive information about how
to file a complaint with Dakota County or with the U.S.
DCPHD-GN-965 (3/22/10)
Department of Health and Human Services, Office for
Civil Rights.
How to file a complaint or report a problem.
If you want to file a complaint or to report a problem
with how Dakota County has used or disclosed
information about you, you may complain to the Dakota
County HIPAA Privacy Official at the address listed
below or to the Office of Civil Rights, Medical Privacy
Complaint Division, U.S. Department of Health and
Human Services.
Your benefits will not be affected by any complaints you
make. Dakota County cannot retaliate against you for
filing a complaint, cooperating in an investigation, or
refusing to agree to something that you believe to be
unlawful.
If you have any questions about this notice or need
more information, please contact the Dakota County
Privacy Officer.
Dakota County
Attn: HIPAA Privacy Official
1 Mendota Road West, Suite 500
West St. Paul, MN 55118
Telephone: (651) 554-5889
ACKNOWLEDGEMENT OF RECEIPT OF
DAKOTA COUNTY HEALTH CARE COMPONENTS
NOTICE OF PRIVACY PRACTICES
PLEASE REVIEW IT CAREFULLY.
The Dakota County Health Care Components Notice of Privacy Practices tells you how Dakota
County may use or disclose information about you. Not all situations will be described. Dakota
County is required to give you a notice of our privacy practices for the information we collect and keep
about you.
I, ______________________________________ (printed name of client), acknowledge that I
have received a copy of Dakota County’s Notice of Privacy Practices on __________________ (date).
Client Signature
Date
Legal or Personal Representative of Client
(if applicable)
Relationship
For Internal Use Only:
Dakota County Employee: Please complete this document and have the individual receiving the Notice
of Privacy Practices sign and date this Acknowledgement. File the original in the client’s case record.
Dakota County Employee: ___________________________________________________________
Complete if the Acknowledgement Form is not signed:
1. Does the client have a copy of the Notice of Privacy Practices?
… Yes
… No
2. Please explain why the client was unable to sign an acknowledgment form and include any
notes about efforts in trying to obtain the client’s signature: __________________________
Amended Version: September 15, 2003
Application for Social Services
To fill out the application online, please click the link for the
DHS Application for Social Services.
To fill out the application by hand, please fill out the scanned
application on the following pages.
DAKOTA COUNTY COMMUNITY SERVICES
DAKOTA COUNTY SOCIAL SERVICES
ADULT SERVICES
1 MENDOTA ROAD WEST, STE 300
WEST ST. PAUL MN 55118-4770
RELEASE OF INFORMATION CONSENT FORM
CHEMICAL HEALTH SERVICES
(FORM IS NOT VALID UNLESS COMPLETED IN FULL)
I,
Services to:
, Birthdate
, authorize Dakota County Social
Exchange with the following individual(s) or entity(ies):
Rule 31 Contracted Providers
The following information:
School Achievement & Behavior Report
Psychological Evaluation
Discharge/Treatment Summary
Bio/Psycho/Social
Rule 25 Assessment
Rule 25 Recommendations/Referral
Progress Note/Treatment Plan Reviews
Summary of Social History
Other
The purpose for disclosure is: Referral and coordination of care at a Chemical Health Treatment Facility.
This consent expires automatically twelve (12) months from the date this consent is signed, unless earlier revoked by me.
I understand that my records are protected under the Minnesota Government Data Privacy Act (Minn. Stat. Chapter 13), the Health
Insurance Portability and Accountability Act of 1996 (45 CFR Parts 160, 162, and 164), and other applicable state and federal privacy
laws. I understand that this information cannot be released without my written consent, unless otherwise authorized by law, and that I
am under NO OBLIGATION to release it. I understand that I may release all, some, or none of the information. I understand that if
there is a child protection hearing, the information collected from me will become public if submitted in a report to the court or if
introduced at court pursuant to Minnesota Rules 44.01 and 44.02 of the Rules of Juvenile Procedure, except for the data specifically
listed in Rules 8.01 through 8.08 of the Minnesota Rules of Juvenile Procedure. I understand that I have a right to see the information
and have a copy of it. I may revoke this Consent at any time in writing, however, revocation will not pertain to data released or
obtained prior to the County’s receipt of the written revocation notice at one of the addresses noted above. Unless I revoke my consent
sooner, my permission to allow the release of this information will automatically expire one (1) year from the date I sign this release.
I understand that in accordance with 45 CFR part 164.508, subd. c (2) (iii), you are informing me that the individual(s) or entities whom
you are authorized to disclose my information to may not be subject to the same privacy rules as Dakota County and there may be the
potential of redisclosure of the private information. I understand that my eligibility to receive benefits from Dakota County Social
Services will not be affected if I refuse to sign this release. However, I also understand that if I refuse to sign this Consent, it could
affect the County’s ability to determine what services I need or am qualified to receive.
Date:
Client Signature:
Person Requesting Release:
Dakota County Social Services
Parent/Guardian:
(if client under 18 or under legal guardianship)
Notice to Recipients of Information: If you have received information related to drug or alcohol abuse by the client, you must
include the following statement when further disclosing information as required by 42 CFR Part 2.32. “This information has been
disclosed to you from records protected by Federal confidentiality rules (42 CFR, Part 2). The Federal rules prohibit you from
making any further disclosure of the information unless further disclosure is expressly permitted by the written consent of the
person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or
other 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.”
SS-CH-DAK4582 (9/2016)
DAKOTA COUNTY COMMUNITY SERVICES
DAKOTA COUNTY SOCIAL SERVICES
ADULT SERVICES
1 MENDOTA ROAD WEST, STE 300
WEST ST. PAUL MN 55118-4770
RELEASE OF INFORMATION CONSENT FORM
CHEMICAL HEALTH SERVICES
(FORM IS NOT VALID UNLESS COMPLETED IN FULL)
I,
Services to:
, Birthdate
, authorize Dakota County Social
Exchange with the following individual(s) or entity(ies):________________________________________________
Obtain from the following individual(s) or entity(ies):___________________________________________________
Release to with the following individual(s) or entity(ies):________________________________________________
The following information:
School Achievement & Behavior Report
Psychological Evaluation
Discharge/Treatment Summary
Bio/Psycho/Social
Rule 25 Assessment
Rule 25 Recommendations/Referral
Progress Note/Treatment Plan Reviews
Summary of Social History
Other_______________________
The purpose for disclosure is: _________________________________________________________________________
This consent expires automatically twelve (12) months from the date this consent is signed, unless earlier revoked by me.
I understand that my records are protected under the Minnesota Government Data Privacy Act (Minn. Stat. Chapter 13), the Health
Insurance Portability and Accountability Act of 1996 (45 CFR Parts 160, 162, and 164), and other applicable state and federal privacy
laws. I understand that this information cannot be released without my written consent, unless otherwise authorized by law, and that I
am under NO OBLIGATION to release it. I understand that I may release all, some, or none of the information. I understand that if
there is a child protection hearing, the information collected from me will become public if submitted in a report to the court or if
introduced at court pursuant to Minnesota Rules 44.01 and 44.02 of the Rules of Juvenile Procedure, except for the data specifically
listed in Rules 8.01 through 8.08 of the Minnesota Rules of Juvenile Procedure. I understand that I have a right to see the information
and have a copy of it. I may revoke this Consent at any time in writing, however, revocation will not pertain to data released or
obtained prior to the County’s receipt of the written revocation notice at one of the addresses noted above. Unless I revoke my consent
sooner, my permission to allow the release of this information will automatically expire one (1) year from the date I sign this release.
I understand that in accordance with 45 CFR part 164.508, subd. c (2) (iii), you are informing me that the individual(s) or entities whom
you are authorized to disclose my information to may not be subject to the same privacy rules as Dakota County and there may be the
potential of redisclosure of the private information. I understand that my eligibility to receive benefits from Dakota County Social
Services will not be affected if I refuse to sign this release. However, I also understand that if I refuse to sign this Consent, it could
affect the County’s ability to determine what services I need or am qualified to receive.
Date:
Client Signature:
Person Requesting Release:
Witness
Parent/Guardian:
(if client under 18 or under legal guardianship)
Notice to Recipients of Information: If you have received information related to drug or alcohol abuse by the client, you must
include the following statement when further disclosing information as required by 42 CFR Part 2.32. “This information has been
disclosed to you from records protected by Federal confidentiality rules (42 CFR, Part 2). The Federal rules prohibit you from
making any further disclosure of the information unless further disclosure is expressly permitted by the written consent of the
person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or
other 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.”
SS-CH-DAK4582 (03/2011)
Dakota County Chemical Health – Client Check-List
Client Name: ______________________________ Date of Assessment: ______________
I have received the Notice of Privacy Practices (Tennessen Warning)
I have received information on HIPAA.
I have received information on Appeal Rights.
I was offered copies of any/all Releases of Information that I signed.
Received Releases
Declined Releases
My signature indicates that I have had the above information given and/or explained to me.
_______________________________
Client Signature
_________________
Date
_______________________________
Dakota County or Dakota County Contracted Representative
Client Placement Authorization DHS-2780-ENG
https://edocs.dhs.state.mn.us/lfserver/Public/DHS-2780-ENG
PRIVACY of ALCOHOL and DRUG ABUSE RECORDS
State laws and federal rules protect your placement and treatment records. The federal rule is Title 42, part 2 of the Code of Federal Regulations.
The state laws are Minnesota Statutes, chapter 13 and Minnesota Statutes, section 254A.09. The agency must not identify you to others without your
consent. Your consent must be in writing.
You do not have to answer the questions on this form. However, the state will not pay for your treatment unless you answer the questions.
Your records are private. Agency employees working on your placement in treatment can see the records. Workers in this agency who arrange for
payment have access to your records. Workers from the Minnesota Department of Human Services who send out treatment payments or check county
records also have access to your records.
Your records may be released outside the agency with your consent. Your records may also be released under the following conditions:
1. You are not identified as an alcohol or drug abuser in any way. This means a treatment center that treats other problems can release your name, but
not say you are receiving alcohol or drug services.
2. A court orders the release of records after a hearing.
3. The disclosure is made during a medical emergency to medical treatment providers.
4. The disclosure is made to an agency which provides services such as bill collecting to the program.
5. A child abuse or neglect report is made. The report identifies the child, the child's caretaker and the alleged abuser. The amount and type of abuse
and the identity of the reporter are also in the report. The abuse may be reported to local welfare or police agencies.
6. Staff in this agency and the Minnesota Department of Human services need the information to do their jobs.
Your alcohol and drug abuse record normally may not be used in criminal investigations. Crimes in programs or against program workers may be
reported to police. A threat to commit a crime also may be reported to police. A court may order release of records if the crime is very serious.
You have the right to see your record. You have the right to obtain a copy of your record. The agency may charge you for the cost of finding the record
and making copies. If you only want to see the record, the agency must provide it at no cost.
Breaking the federal privacy rule is a crime. The penalty is a fine of not more than $500 for the first offense and not more than $5,000 for repeat
offences.
Suspected violations may be reported to:
United States Attorney
District of Minnesota
300 South 4th Street, Room 600
Minneapolis, Minnesota 55401
You may complain if your record is wrong. You may also complain if your record is not complete. The agency must reply within 30 days. If you disagree with the agency's decision, you may appeal to the State Department of Administration. Your appeal should include:
1. Your name, address, and telephone number,
2. The name and address of the agency which has the records,
3. Description of the dispute and the date it happened, and
4. The relief you want.
If an agency breaks the state privacy law, you may also sue. Damages of not less than $100 or not more than $10,000 can be assessed by a court
against the agency. Workers who break this law are guilty of a misdemeanor.
DISCRIMINATION COMPLAINT PROCESS
If you believe you have been discriminated against because of your race, color, creed, religion, national origin, disability, sex, sexual orientation,
public assistance status, or age, while requesting or receiving alcohol or other drug abuse treatment services, you may file a discrimination complaint
with one or more of the agencies listed below:
Minnesota Department of Human Services
Office for Equal Opportuniity
PO Box 64997
St. Paul, MN 55164-0997
Minnesota Department of Human Rights
Army Corps of Engineers Center
190 East Fifth Street, Suite 700
St. Paul, MN 55101
U.S. Department of Health and Human Services
Office for Civil Rights, Region V-Chicago
233 North Michigan Avenue, Suite 240
Chicago, IL 60601-5519
Clear Form
*DHS-2794-ENG*
DHS-2794-ENG
12-13
Rule 25 Assessment and Placement Summary
CLIENT NAME
PMI
ASSESSOR
ASSESSMENT DATE
General Guideline
Original
Update
Clients should be offered the least restrictive referral consistent with sound clinical judgment. All items must be clearly
documented in the Assessment Tool. This form must remain in the client file. Check the severity rating for each dimension and
document the provider(s) who will meet the identified needs.
Dimension
I
Intoxication/
Withdrawal
II
Biomedical
III
Emotional/
Behavioral/
Cognitive
IV
Readiness for
Change
V
Relapse and
Continued Use
VI
Recovery
Environment
Severity Rating
0
1
2
3
4 = Crisis
0
1
2
3
4 = Crisis
0
1
2
3 = SC + R&B
4 = Crisis
0
1
2
3 = SC
4 = SC + R&B
0
1
2
3 = SC
4 = SC + R&B
0
1
2
3 = SC
4 = SC + R&B
Service Coordination
(if required above)
Room & Board, if not paid for
through the CCDTF
(if required above)
Page 1 of 2
Provider Name and Contact Information
Assessment Summary Rule 25 Chemical Use Assessment
CLIENT NAME
PMI
ASSESSOR
ASSESSMENT DATE
General Guideline
This page should record a summary of the information gained from the client and collateral sources that lead to the severity
rating. It should be essentially the same as the information given in the “reasons” section after each dimension in the Rule 25
Assessment Tool. This form must be completed. The “reasons” sections do not need to be completed if this form accompanies
each completed assessment tool. Each severity rating must be clearly documented in the client file. This form should remain in the
client file.
Dimension
Risk Rating
Rationale
0
I
1
Intoxication/
Withdrawal
2
3
4
0
II
Biomedical
1
2
3
4
III
Emotional/
Behavioral/
Cognitive
0
1
2
3
4
0
IV
1
Readiness for
Change
2
3
4
0
V
1
Relapse and
Continued Use
2
3
4
0
VI
1
Recovery
Environment
2
3
4
Page 2 of 2
DHS-2794-ENG 12-13