Patient Consent
Consent to Treat
By signing this agreement, you authorize the health care providers and their designees at The Bodhi Clinic to conduct interviews, examinations, assessments, diagnostic testing and procedures to assess your mental and physical health care conditions, and to use the following, but not limited to, services including nutrition counseling, lifestyle advice, psychology, nutrients, herbs, supplements, holistic therapies, pharmaceuticals and procedures in the attempt to render medical care, to diagnose and to treat you. You understand that it is the responsibility of your treating health care provider(s) to explain the nature of proposed care, treatment, services, prescribed medications, suggested interventions, procedures, or tests. Before you undergo particular procedures or tests, your provider(s) will explain the potential benefits, risks, side effects, or reasonable alternatives to the procedures or tests. This consent form does not take the place of an informed consent form for a particular procedure or test. You understand that results or outcomes from any treatment advised or rendered from health care providers at The Bodhi Clinic are not guaranteed. This signed agreement is valid and applicable to all past, present and future visits obtained through The Bodhi Clinic.
A. Right to Refuse Treatment. You understand that you retain the right to refuse any particular examination, test, procedure, treatment, therapy, supplement or medication recommended or deemed medically necessary by my treating health care provider(s). You have the right to seek alternative medical care and obtain second opinions. The Bodhi Clinic encourages all patients to consult and continue their medical care with a Primary Care provider and any medically required specialists regarding both ongoing and future medical treatments advised or rendered from The Bodhi Clinic.
B. Declaration of medical history. You understand that it is your responsibility to inform the treating provider of both past and current mental and physical history, including but not limited to, medical diagnoses, treatments, medications, supplements, over-the-counter drugs, conditions, surgeries, allergies, family history, pregnancy and breast feeding status.
C. Natural therapies. Health care providers at The Bodhi Clinic may recommend holistic and natural therapies within their scope of practice, including, but not limited to, herbs, botanical, homeopathic supplements, nutrients, trace elements, amino acids, vitamins, and minerals. If any supplements have been recommended by your Provider, you may purchase them wherever and from whomever you prefer and you understand that you may choose whether or not to take them.
According to the Federal Food, Drug, and Cosmetic Act, as amended, Section 201(g)(1), the term “drug” is defined as an “article intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease.” Technically, vitamins, minerals, trace elements, amino acids, herbs, botanical or homeopathic remedies are not classified as drugs; therefore, these substances may not be regulated by the U.S. Food Drug Administration and are not used to cure or treat any health condition. At The Bodhi Clinic, you may receive nutritional counseling and individualized recommendations regarding use of these substances as deemed appropriately to optimize health and function. However, these substances can have significant effects on physiology and must be used rationally. The use of these natural therapies may be recommended for patients already using pharmaceutical medications (i.e. drugs), but some potentially harmful interactions may occur. For this reason, it is important to keep all of your healthcare providers fully informed about your full medical history, including any current medications, supplements and over-the-counter products.
D. Results. As with any health care, treatment results cannot be guaranteed and may result in unexpected adverse events.
Telehealth Consent
By signing this agreement, you understand that The Bodhi Clinic offers video telehealth services to better serve the needs of the community. While the type of appointment selected, either in-person or video telehealth visit, is your preference, by signing this agreement you consent to abiding by the requirements for a telehealth visit listed below and to participate in a video telehealth visit should you choose to.
You understand that telehealth involves the use of electronic communications to enable healthcare services when the patient and provider are not in the same physical location. You acknowledge that telehealth may include the exchange of medical information through secure audio, video, or other digital means, and that while reasonable efforts are made to protect privacy and confidentiality, there are inherent risks associated with electronic transmission. You understand the limitations of telehealth, including the inability to perform certain physical examinations, and agree that the provider may determine when an in-person visit is necessary.
You are responsible for ensuring your surroundings are private. If your provider determines your privacy or focus is compromised (e.g., being in a public place, operating a motor vehicle or engaging in distracting activities), the visit will be ended, and standard cancellation fees will apply. Telehealth depends on technology. Issues like dropped connections, poor audio/video quality, or rare security breaches may require the session to be terminated or rescheduled. Recording of any session is strictly prohibited without explicit prior permission.
Policies & Fees:
A. Location. You must be physically located in a state where your provider is licensed at the time of service.
B. Financials. The same fee schedule applies to telehealth as in-person visits, including late cancellations and no-show fees.
C. Alternatives.You may request an in-person visit at any time, subject to public health guidelines or national emergencies.
Consent to Use of AI Charting Software
By signing this agreement, you consent to the use of AI dictation technology in the documentation of medical records at The Bodhi Clinic.
AI dictation technology is used to transcribe spoken conversations during appointments into written documentation. This tool enhances efficiency and accuracy in clinical note-taking. AI-generated notes are always reviewed and finalized by your Provider and are not used to make clinical decisions independently.
A. The protection of your personal health information. All data is encrypted and secured in accordance with HIPAA regulations. Only authorized healthcare providers have access to transcriptions. Transcripts are retained only as long as necessary for documentation purposes and are deleted in accordance with our data retention policies. Business Associate Agreements (BAAs) are in place with AI service vendors.
B. Your rights. You have the right to access your clinical documentation and transcripts, request corrections for any inaccuracies and review the privacy policies and terms of service used by the AI vendor.
C. Benefits of AI use. More accurate and timely documentation, improved efficiency and workflow, and more focused face-to-face time with your provider
D. Potential Risks of AI use. Occasional transcription errors and AI limitations in recognizing unclear or overlapping speech.
By signing this agreement, you acknowledge that you have read and understood this consent form and voluntarily agree to the use of AI dictation services . You may have the opportunity to ask questions by emailing admin@bodhiclinic.org. You may be able to revoke this consent with the mutual consent of your Provider.
Financial Responsibility and Fees
By signing this agreement, you understand and acknowledge that you are financially responsible for paying all costs associated with the health care services that you receive from The Bodhi Clinic. You understand that you are financially responsible for such costs even if you have health insurance, depending on the benefits and coverage limitations of your health insurance policy.
The Bodhi Clinic does not contract with insurance companies, nor bill them, and does not guarantee insurance coverage for the services, labs and products ordered and rendered. The Bodhi Clinic is a cash-pay clinic in which the service is purchased up front with the card on file and rendered appropriately after receiving the payment. These rendered services are non-refundable. The Bodhi Clinic does accept credit, debit and HSA/FSA accounts as payment. You may attempt to receive reimbursement from your insurance company (if it is a commercial plan that is not state medical assistance, Medicare, Medicaid or out-of-state insurance) by requesting a Superbill from The Bodhi Clinic and submitting that to your insurance company. It is your responsibility to check your insurance plan and determine coverage, if any. You understand that depending on your insurance coverage that you may be unable to obtain reimbursement for any service rendered, laboratory tests ordered, and medication or supplement received. The Bodhi Clinic is not an insurance plan and it is strongly advised that you maintain insurance coverage and a relationship with a Primary Care Provider outside of the services offered at The Bodhi Clinic.
The cost of the appointment does not include additional tasks, duties or services requested by you outside of the allotted visit time of the appointment. In the event that the patient requests additional services outside of the allotted visit time, additional fees may incur. Possible requested tasks, duties or services requested outside of the purchased allotted visit time of the appointment may include, but is not limited to, letters, faxes, paperwork completion, medical necessity forms, work accommodations, prior authorizations, and lab orders (see Laboratory Testing). These requested tasks, duties or services will be billed at an hourly rate for the Provider utilized. You may find this hourly rate pricing our website. These prices are subject to change without notice, nor do they include a grandfather clause or guaranteed rate.
Communication with the provider outside of the purchased allotted visit time (see Communication and Emergency Policy) may be requested via the Patient Portal messaging system through the provided HIPPA-compliant EHR. Once requested, the Provider or admin from The Bodhi Clinic will quote the expected fee for the message response, and if agreed on by you, will charge your card on file appropriately (see Payment Processing). If the expected response to said message requires greater than 10 minutes of time from the Provider, the Provider or The Bodhi Clinic reserves the right to request an appointment instead.
The Providers at The Bodhi Clinic will inform you and quote you of any additional fees that may incur before the completion of the requested tasks, duties or services outside of the allotted purchased appointment time. Should the requested tasks, duties or services and their cost to you be approved by you (either verbally or in written format) and mutually agreed upon by the Provider tasked to perform such duty, the Provider will charge the appropriate fee to your card on file (see Credit Card Authorization and Permission and Consent to Treat). These requested tasks, duties or services are non-refundable once performed (see Refund Policy).
It is expected that you honor and abide by the time allotted of the purchased visit. Should you go over the allotted time of the purchased visit, intentionally or unintentionally, the Provider has the right to stop the visit or quote you for the cost any additional time. Should the extra visit time and cost of said extra visit time be approved by you (either verbally or in written format) and mutually agreed upon by the Provider tasked to perform such duty, the Provider will charge the appropriate fee to your card on file (see Credit Card Authorization and Permission and Consent to Treat).
By signing this agreement, you acknowledge and accept these terms.
Laboratory Testing
The Bodhi Clinic may recommend conventional lab tests, as well as functional medicine laboratory tests, to obtain needed additional data in the effort of understanding the patient’s health. The purpose of laboratory testing is to evaluate nutritional, biochemical, or physiological imbalance and to determine any need for medical intervention. You understand that the costs of both conventional and functional medicine laboratory tests are not covered in the cost of the visit with the provider. You will be alerted to all fees of laboratory tests in advance, and have the right to decline some or all recommended laboratory testing. All laboratory tests ordered are non-refundable.
Once The Bodhi Clinic or ordering provider receives the results of the completed lab tests, the results will be shared with the patient without interpretation at no cost. You understand that the interpretation of these labs require additional provider time; therefore, the Provider may include an interpretation fee included in the cost of the laboratory testing and/or an additional paid visit with a Provider to go over any and all lab results and interpretations.
Additionally, The Bodhi Clinic does not bill insurance directly for either conventional or functional medicine labs. The laboratories themselves may or may not directly bill your insurance. You may attempt to receive reimbursement after the completion of the labs from your insurance company (if it is a commercial plan that is not state medical assistance, Medicare or Medicaid) by requesting a Superbill from The Bodhi Clinic and submitting that to your insurance company. You understand that you are financially responsible for such costs even if you have health insurance, depending on the benefits and coverage limitations of your health insurance policy.
If you would like your Provider to attempt to bill the labs through your commercial insurance plan, there will be a non-refundable, flat fee of $50.00. This is to ensure that your Provider is compensated for the extra administrative time that incurs for working outside of our EHR, manually enter each lab into a document, and to fax in the lab order to the laboratory of your choice.
By signing this agreement, you acknowledge and accept these terms.
Payment Processing
By signing this agreement, you agree to keep a valid credit card or bank account on file with The Bodhi Clinic’s EHR system, a secure and HIPPA compliant platform, both before your initial visit and ongoing after. This method of payment will be used for all services, including treatment, products, and fees. You reserve the right to change your credit card information on file by alerting The Bodhi Clinic and requesting that change. Patients are responsible for all charges, regardless of insurance coverage, as The Bodhi Clinic does not accept insurance as payment for any services rendered. Additionally, the card on file will be charged for cancellation fees, as well as any banking fees or chargebacks resulting from payment issues caused by the patient.
Appointment Scheduling
By signing this agreement, you agree to complete any necessary Intake Paperwork and submit it no less than 48 hours before the appointment time to ensure the Provider at The Bodhi Clinic has the ability to review the necessary information. Failure to do so will result in the appointment cancellation or rescheduling (see Cancellation, Reschedule and Late Fee Policy below).
If The Bodhi Clinic or the Provider believes there is a more appropriate appointment type for the items you would like to address, we may reach out to you and suggest an alternative appointment type. If the appointment is mutually agreed upon by you and The Bodhi Clinic to be changed, the difference in the amount due will be applied to the card on file. If the appointment is not changed despite the Provider's attempt to reach out, the appointment type will remain the same; however, the Provider cannot guarantee all concerns, labs and/or imaging will be covered in the allotted time as requested.
Cancellation, Reschedule and Late Fee Policy
The Bodhi Clinic values you as a patient and looks forward to caring for you. When you book an appointment, The Bodhi Clinic and their Providers block their schedule for you and ask that you exercise the same consideration by adding the scheduled appointment to your calendar. We do not want missed appointment fees to be an impediment to your care; however, The Bodhi Clinic needs to ensure that Providers are compensated for their time. By signing this agreement, you agree to our cancellation notice of at least 48 business hours. For example, if your appointment time was 8:00 am on Wednesday, you have until 8:00 am on the Monday before Wednesday to cancel or reschedule the appointment. Another example would be if your appointment was Monday at 8:00 am, you have until 8:00 the Thursday before that Monday to cancel or reschedule the appointment. If the appointment is cancelled or rescheduled at least 48 hours before the time of your appointment, 100% credit will be applied towards a reschedule. If the appointment is cancelled or rescheduled at least 48 hours before the time of your appointment with intent to not to complete the visit, the total cost of the visit less the credit card processing fees necessary to process that payment will be refunded to the original payment method.
Failure to comply with the 48 business hour notice requirement will result in a cancellation and rescheduling fee.
There will be a cancellation fee of 50% of the cost of the visit if the appointment is cancelled or rescheduled within 48 hours of the appointment time, this excludes a no-show or same-day cancellation (see policy regarding that below). The remaining 50% of the appointment cost will be applied towards a future rescheduled appointment. If the appointment is cancelled or rescheduled within 48 hours before the time of your appointment with intent to not to complete the visit, the total cost of the visit less the credit card processing fees necessary to process that payment will be refunded to the original payment method. If the appointment is cancelled with intent to not complete the appointment, 50% of the cost of the visit less the credit card processing fees necessary to process that payment will be refunded to the original payment method.
No-Show or a same-day cancellation fee is 100% of the cost of the visit.
If you are more than 15 minutes late past the scheduled appointment time, The Bodhi Clinic considers this a same-day cancellation and no-show; therefore, the fee will be 100% of the cost of the visit. The Bodhi Clinic and their Provider is not obligated to start the appointment at the time of late arrival; however, if The Bodhi Clinic or their Provider chooses to allow the visit to continue despite the late arrival, the visit will end at the original scheduled time to end and the charge will still be 100% of the cost of the visit.
All services rendered at the time of the appointment, even partial, are non-refundable.
If frequent reschedules, cancellations, no-shows or late arrivals occur, The Bodhi Clinic reserves the right to consider and pursue the termination of your patient relationship with The Bodhi Clinic and its providers (see Termination of Services Policy).
By signing this agreement, you acknowledge and accept these terms.
Refund Policy
All non-edible, non-damaged and un-opened products purchased in-store at The Bodhi Clinic are eligible for a refund, less a restocking fee of 3% of the purchase price, within 14 days of purchase.
All services rendered are not eligible for refunds. If the appointment is cancelled or rescheduled at least 48 hours before the time of your appointment with intent to not complete the visit, the total cost of the visit less the credit card processing fees necessary to process that payment will be refunded to the original payment method (see Cancellation, Reschedule and Late Fee Policy).
By signing this agreement, you acknowledge and accept these terms.
Communication and Emergency Policy
By signing this agreement, you voluntarily agree to our communication and emergency policy.
A. Electronic Health Record (EHR) Patient Portal Messages. You will have access to our HIPPA-compliant EHR system’s Patient Portal. The Patient Portal allows you to send a message to your Provider(s) and is the preferred form of communication between you and your care team to ensure your private information remains confidential. You understand that requesting to receive a message from your Provider may incur a fee and require that a payment of said fees be made in advance. While the Provider or administration team at The Bodhi Clinic may offer simple clarification on an existing treatment plan without a fee, extensive clarification, new or previously unaddressed concerns, or any treatment plan changes may result in the fees or the need for an appointment (see Financial Responsibility and Fees).
B. Clinic and Provider Access. The Bodhi Clinic is open Monday through Friday from 8 am to 5 pm and by appointment only. The Bodhi Clinic may also close additional hours or days at its own discretion for, including, but not limited to, Federal holidays, renovations, staff meetings and other reasons. We do not offer 24/7 phone access, RN triage or Provider care. You may leave a message with The Bodhi Clinic’s admin team at 612-276-2526. The Bodhi Clinic and its Providers are not guaranteed to respond outside of closed business hours, but will attempt to respond and address concerns within 72 business hours.
C. Emergencies. You understand that The Bodhi Clinic is not a crisis facility, an urgent care or a medical emergency facility. We cannot guarantee same-day appointments. If you are in need of urgent or emergent care, we advise you to call 911 or go to the nearest emergency room. You may also contact the Suicide Hotline at 1-800-273-TALK (8255) or the National Maternal Mental Health Hotline at 1-833-TLC-MAMA (852-6262).
D. Marketing and Other Communication. By providing your email address you consent to receiving marketing and other communication from The Bodhi Clinic and its Providers. The Bodhi Clinic agrees to not sell or share any of your personal data with third-party vendors. You may opt out of receiving marketing communications or email communications by informing your Provider, the admin team of The Bodhi Clinic or by selecting “Unsubscribe” at the bottom of your email. You may also receive text notifications or phone calls regarding appointment reminders and updates. You may also opt out of receiving these notifications by informing the admin team of The Bodhi Clinic or your Provider.
Minor and Parental Consent
For patients under the age of 18 years old, The Bodhi Clinic requires written or verbal parental consent for all appointments, unless permitted otherwise under MN State Law.
If you are a parent of a patient under the age of 18 years old and give verbal parental consent, The Bodhi Clinic will keep the permission valid in the patients chart. You may revoke this consent by informing The Bodhi Clinic or its Provider(s).
If you are a patient under the age of 18, The Bodhi Clinic and its Providers may require your parents to be present during a portion of the visit to ensure that they are consenting to treatment. By signing this agreement, you understand that your parents may be legally entitled to some information about your treatment. We will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.
By signing this agreement, you acknowledge and accept these terms.
Profit Disclosure
By signing this agreement, you understand that any cash-pay laboratories and wholesale product(s), including labs (both conventional and functional), in-house pharmaceuticals or supplements, and supplements through Fullscript, recommended or prescribed by providers at The Bodhi Clinic may offer a profit to the recommending and/or prescribing provider. By utilizing laboratories that accept cash-pay, wholesale supplements and in-house pharmaceuticals, providers at The Bodhi Clinic are able to offer our patients labs, supplements and pharmaceuticals at a fair market value, reduce the burden and cost of third-parties or intermediates, and utilize the profit to cover the cost of consultation or other administrative tasks. You are not obligated to purchase any of the recommendations offered by the providers at The Bodhi Clinic. The providers at The Bodhi Clinic are committed and bound to the ethics of our governing boards, agencies and state laws and agree to provide justification for any recommendation or prescription provided.
Additionally, The Bodhi Clinic may receive financial benefit with the use of any associated promotions, sales or promo codes made available to our patients.
Rights of Goods Shared
By signing this agreement, you understand that you may receive personalized services, products, information, materials, technology and other intellectual property (aka Goods) from The Bodhi Clinic and its Providers. This does not grant you any ownership, licensure or rights over the goods received, and you agree to not attempt to claim any such rights in the future. You further acknowledge that all goods received by you have been developed or owned by The Bodhi Clinic and its Providers and full ownership will remain with The Bodhi Clinic and its Providers. You agree to not share, copy, distribute, change, or edit any goods received.
Termination of Services Policy
By signing this agreement, you understand that there may be circumstances that lead to the termination of the patient-provider relationship or patron-server relationship on behalf of The Bodhi Clinic or its Providers.
Patients with a pattern of frequent late late cancellations or no shows are subject to termination. Patients who have not had an appointment longer than 12 months will be considered discharged, and may be treated as a new patient should they desire to be seen again after 12 months; applicable appointment fees will apply. The Bodhi Clinic welcomes all patients to return at whatever time suits them.
Patients or patrons who engage in behavior, language or acts that may be viewed or received as disrespectful by the Provider or The Bodhi Clinic may have their relationship terminated non-reversibly. This includes slander and/or an attempt to discredit the Provider or The Bodhi Clinic without proven just cause. Any and all acts of harm, perceived or performed by patients or patrons, will result in immediate and non-reversible termination and a ban from the premises and surrounding 200 feet located at 3018 W 56th St, Minneapolis, MN 55410. The Bodhi Clinic reserves the right to keep its business, premises, staff and Providers safe and free from harm, perceived or performed. We reserve the right to involve litigation, legal counsel and police or emergency responders as deemed necessary.
Terms and Conditions
By signing this agreement, you voluntarily agree to the following terms and conditions.
A. Social Media Policy. You are welcome to interact with The Bodhi Clinic’s social media accounts. We ask for respectful behavior (see Termination of Services Policy) during all matters of engagement, including but not limited to, leaving comments, sharing posts or interacting with other patients or patrons. Social media accounts are not confidential and we ask that you keep this in mind while sharing any public information. We agree to not share any of your confidential or private information. Honoring the patient-provider relationship and adhering to ethical standards, we ask that you avoid social media interaction with your direct care team and Provider.
B. No Recording Policy. The Bodhi Clinic and its Providers do not allow recording of any kind, visual or audio, during appointment times. Recordings may jeopardize patient and provider confidentiality. Furthermore, failure to seek consent from the Provider in the setting of unauthorized recordings damage the patient-provider relationship and may result in termination (see Termination of Services Policy).
C. Disabilities Rights and Access. Certified service animals are welcomed and allowed; however, must be within 2 feet of your person at all times. Emotional support animals, however, are not allowed at The Bodhi Clinic at this time. The Bodhi Clinic has stairs to access the clinic and it is not achievable at this time to remove those stairs as a barrier. The Bodhi Clinic and its Providers look forward to any future or new construction the building and its owners may offer; however, in the meantime we are only able to offer virtual telehealth appointments to those who may experience the stairs to be a barrier (see Telehealth Consent).
Questions, Concerns or Complaints
We at The Bodhi Clinic handle your concerns respectfully and take all reports seriously. If you have any questions, concerns or complaints about your treatment or billing charge, you can speak with your Provider or contact the administration team at (612) 276-2526. There will be no punishment or penalization for expressing concerns, making complaints or asking questions.
If you desire to file a formal complaint, you may do so with your Provider’s appropriate licensing board:
MN Board of Social Work (LICSW) (612) 617-2100
MN Board of Marriage and Family Therapy (LMFT) (612) 617-2220
MN Board of Behavioral Health & Therapy (LADC, LPC & LPCC) (612) 548-2177
MN Board of Psychology (LP) (612) 617-2230
MN Board of Nursing (APRN, PMHNP) (612) 317-3000
MN Board of Medical Practice (PA, MD) 612-617-2130