1. Practitioner Information
Name: [Practitioner full name]
Title: Complementary and Alternative Health Care Practitioner (Homeopathy)
Business Address: [Business address] — practice conducted remotely by video conference and telephone
Telephone: [Phone number]
Email: [Email address]
2. Qualifications and State Disclosure
Degrees, training, experience, and other qualifications:
[Graduate, Academy of Homeopathy Education — add diploma/certification details and years of training]
THE STATE OF MINNESOTA HAS NOT ADOPTED ANY EDUCATIONAL AND TRAINING STANDARDS FOR UNLICENSED COMPLEMENTARY AND ALTERNATIVE HEALTH CARE PRACTITIONERS. THIS STATEMENT OF CREDENTIALS IS FOR INFORMATION PURPOSES ONLY.
Under Minnesota law, an unlicensed complementary and alternative health care practitioner may not provide a medical diagnosis or recommend discontinuance of medically prescribed treatments. If a client desires a diagnosis from a licensed physician, chiropractor, or acupuncture practitioner, or services from a physician, chiropractor, nurse, osteopathic physician, physical therapist, dietitian, nutritionist, acupuncture practitioner, athletic trainer, or any other type of health care provider, the client may seek such services at any time.
3. Supervisor
None — solo practice.
4. Complaints Against This Practice
You may file a complaint directly with the practitioner by contacting [phone/email]. Complaints will be acknowledged within [X] business days and addressed promptly.
5. Complaints to the State of Minnesota
You may file a complaint with the Office of Unlicensed Complementary and Alternative Health Care Practice, Minnesota Department of Health:
Minnesota Department of Health
P.O. Box 64882, St. Paul, MN 55164-0882
Phone: 651-201-3798
Web: https://www.health.state.mn.us
6. Fees and Billing
- Fees per unit of service: [e.g., initial consultation $X for 90 minutes; follow-up $Y for 45 minutes]
- Method of billing: [invoicing/payment methods accepted]
- Insurance: [Names of any insurance companies that have agreed to reimburse the practitioner, or HMOs with which the practitioner contracts, or "None"]
- Medicare / Medical Assistance: [Does/does not accept]
- Partial payment or waiver: [Whether willing, and in what circumstances]
7. Notice of Changes
Clients have the right to reasonable notice of changes in services or charges.
8. Theoretical Approach
[Plain-language summary of homeopathy and the practitioner's approach, e.g.: "Homeopathy is a system of natural health care that uses highly diluted substances to stimulate the body's self-healing response. My approach involves detailed consultations to understand the whole person..."]
9. Information About Assessment and Services
Clients have the right to complete and current information concerning the practitioner's assessment and recommended service to be provided, including the expected duration of the service.
10. Courteous Treatment
Clients may expect courteous treatment and to be free from verbal, physical, or sexual abuse by the practitioner.
11. Confidentiality
Client records and transactions with the practitioner are confidential, unless release of these records is authorized in writing by the client, or otherwise provided by law.
12. Access to Records
Clients have the right to access records and written information from records in accordance with Minnesota Statutes, sections 144.291 to 144.298.
13. Other Available Services
Other services may be available in the community. Information concerning available services can be obtained from your county public health agency, the Minnesota Department of Health (https://www.health.state.mn.us), or by asking this practitioner.
14. Freedom of Choice
Clients have the right to choose freely among available practitioners and to change practitioners after services have begun, within the limits of health insurance, medical assistance, or other health programs.
15. Coordinated Transfer
Clients have the right to coordinated transfer when there will be a change in the provider of services.
16. Right to Refuse Services
Clients may refuse services or treatment, unless otherwise provided by law.
17. Rights Without Retaliation
Clients may assert their rights without retaliation.