PARTICIPANTBILL OF RIGHTS

Participant ______Service Initiation Date _____/_____/_____

As someone who receives services from PossAbilities of Southern Minnesota you have the rights listed below. Restriction of your rights is allowed only if determined necessary to ensure your health, safety, and well-being. Any restriction of your rights must be documented in your Coordinated Service and Support Plan or Coordinated Service and Support Plan addendum.

Service Related Rights

  1. The right to receive written information about rights on the day of initiation of services and an explanation of the rights within five working days of service initiation;
  2. The right to participate in the development and evaluation of the services provided;
  3. The right to have services and support identified in the coordinated service and support plan and the coordinated service and support plan addendum provided in a manner that respects and takes into consideration your preferences and choices;
  4. The right to receive support in requesting changes to current services, transitioning to other services, or requesting a change of staff.
  5. The right to refuse or terminate services and be informed of the consequences of refusing or terminating services;
  6. The right to know, in advance, limits to the services available from PossAbilities, including our knowledge, skill and ability to meet your service and support needs;
  7. The right to know conditions and terms governing the provision of services, including PossAbilities admission criteria and policies related to temporary service suspension and service termination;
  8. The right to a coordinated transfer when there will be a change in provider to ensure continuity of care;
  9. The right to know what the charges are for services, regardless of who will be paying for the services and be notified of changes in those charges;
  10. The right to know in advance whether services are covered by insurance, government funding or other sources and be told of any charges you or other private party may have to pay; and
  11. The right to receive services from individuals who are competent and trained, who have professional certification or licensure, as required, and who meet additional qualifications identified in your coordinated service and support plan or coordinated service and support plan addendum.

Protection Related Rights

  1. The right to have personal, financial, service, health and medical information kept private and be advised of disclosure of this information by PossAbilities;
  2. The right to access records and recorded information about you in accordance with applicable state and federal law, regulation or rule;
  3. The right to be free from maltreatment;
  4. The right to be free from restraint, time out or seclusion except for emergency use of manual restraint to protect you from imminent danger to yourself or others according to requirements of applicable state rules and regulations;
  5. The right to receive services in a clean and safe environment when PossAbilities is the owner, lessor or tenant of the service site;

05/27/20171

Revised & Reviewed by Senior Leadership

  1. The right to be treated with courtesy and respect,when present to be included in conversation, addressed by your preferred name, and receive respectful treatment of your property;
  2. The right to reasonable observance of cultural and ethnic practice and religion;
  3. The right to be free from bias and harassment regarding race, gender, age, disability, spirituality and sexual orientation;
  4. The right to be informed of and use PossAbilities grievance policy and procedures;
  5. The right to know the name, telephone number, website, email and street addresses of protection and advocacy services and a brief description of how to file a complaint with these offices;

Office of the Ombudsman for Mental HealthMinnesota Disability Law Center

and Developmental Disabilities430 1st Ave N, Suite 300

121 7th Place E, Suite 420Minneapolis, MN 55401

Metro Square BuildingEmail:

St. Paul, MN 55101Website:

Phone: (651) 7567-1800 or 1(800) 657-3506

Fax: (651) 797-1950

Website:

  1. The right to assert these rights personally or have them asserted by your family, authorized representative or legal representative without retaliation;
  2. The right to give or withhold written informed consent to participate in any research or experimental treatment;
  3. The right to associate with other persons of your choice;
  4. The right to personal privacy; and
  5. The right to engage in chosen activities.

These rights are established for the benefit of individuals receiving services from PossAbilities of Southern Minnesota. PossAbilities may not require you to surrender these rights as a condition of receiving services. A legal representative or, when there is no legal representative, a designated person, may seek to enforce these rights on your behalf. This statement of rights does not replace or diminish other rights and liberties that may exist relative to persons receiving services. If you wish to file a complaint, you may contact PossAbilities’ Executive Director Eileen Wallace at (507) 281-6116.

YesNoI received a written copy and an explanation of these rights in a form I could understand.

YesNoI understand that if my rights are or will be restricted in any way

the restriction will be explained to me and I understand that the

restriction must be documented and implemented as required by

law to make sure I get my rights back.

Rights restrictions No Yes, see Notice of Rights Restriction

______/_____/_____

Name & SignatureDate

Participant/Legal Representative

05/27/20171

Revised & Reviewed by Senior Leadership