Complementary & Alternative Health Care Client Bill of Rights

Practitioner Name: Lorri J Kulberg, CR    Business Name: Life in Balance, LLC

Business Mailing Address: 15260 182nd Ave NW Elk River, MN 55330, Physical Address: 107 Cedar Street Monticello MN 55362

As of July 1, 2001, Minnesota’s Freedom of Access to Complementary Care Law (Statute Chapter 146A) requires that you receive and acknowledge that you have received by your signature on the back of this page, the following information prior to your treatment.

2) Lorri J Kulberg, CR, “the Practitioner” has the received following education, training & credentials:

The Information that follows in quotation marks is required to be on the Client Bill of Rights in bold print by the state statute:

"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, osteopath, 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) Supervision: If the Client has a complaint or concern about the care or services you have received, the Client may contact the Practitioner: Lorri Kulberg, Owner: 15260 182nd Ave NW Elk River MN 55330 Telephone number: 612-810-1440.

4,5) Complaints: If the Client has a complaint or concern about the care or services they have received, the Client may also contact the Office of Unlicensed Complementary and Alternative Health Care Practice located in Minnesota Department of Health: Mailing address: P.O. Box 64882,   St. Paul, MN    55164-0882 Phone: 651-201-3728         Fax: 651-201-3839             Website: www.health.state.mn.us 

6) Fees, Payment, Insurance: Fees for Reflexology at the Practitioner’s office are as follows, $15 - $300 with all taxes excluded: Prices vary upon type of bodywork and length of session, Please see brochure for price listings. Payment is acceptable by cash, check or credit card. This Practitioner is not on contract with any HMO’s, PPO’s, or any other Insurance Company to provide discounted services. This Practitioner does directly accept payment from Personal Injury Claims with prior consent from client’s medical doctor and referrals from client’s doctor or chiropractor. Payment in full for services is expected at the time of service, unless otherwise arranged prior to the appointment. Life in Balance, LLC requires 4 hours notice for cancellations. Any session starting late or cancelled will be subject to payment. Please see policy form for more detail. 7) Change of Price: While changes in session fees can occur, reasonable notice of those changes is provided by session fees being posted in the Practitioner’s office, or by the client asking when scheduling the appointment. 8) Theory of Treatment: The state requires a “Plain language” summary of the “theoretical approach used to provide service to clients”. The Practitioner utilizes Reflexology, Essential Oils and Intuitive Healing techniques to help the clients reduce pain, improve circulation of blood and lymph. 9) Right to Current Information: Clients have the right to complete and current information concerning the practitioner's assessment and recommended service that is to be provided, including the expected duration of the service to be provided. 10) Personal Interaction: Clients have the right to expect courteous treatment, free from verbal, physical, or sexual abuse. 11) Right to Confidentiality: Client records are confidential and will not be released, unless authorized by the client in writing or as otherwise provided for by law. 12) Right to Self Access: Clients have the right to access to their own records maintained by the Practitioner’s office, in accordance with state statute sections 144.291 to 144.298; 13) Other Treatment Available: Other reflexology services are available to the Client in this same community.  These can be located by asking the Practitioner, the provider who referred you to this practitioner or the following practitioner database: www.abmp.com 14) Right of Agency: The Client has 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) Records Transfer: The Client have the right to coordinated transfer of your records when there will be a change in the provider of services 16) Right of Refusal: The Client may refuse services or treatment, unless otherwise provided by law. 17) Right of No retribution: The Client has the right to assert the any and all of above-mentioned rights without retaliation from the Practitioner.

Life in Balance, LLC  / Client Policies

My requirements of clients:

~ Sessions begin and end at scheduled times. Sessions begun late due to the client arriving late will end at the appointed time and are full price.

~ Be present (not under the influence of alcohol or drugs).

~ Clients provide a health history and update when necessary.

~ Payment is expected at the time service is rendered. Life in Balance accepts cash, checks, Venmo and most credit cards. Health

Savings Accounts and FLEX spending are also accepted.

~ Sexual harassment is not tolerated. If the practitioner’s safety feels compromised, the session is stopped immediately.

~ This office is a non-smoking environment.

~ Be clean, having showered the same day as the treatment.

~ Do not eat a heavy meal less than two hours prior to treatment.

~ Drink plenty of water the day before, day of and day after your session.

What clients can expect from us:

~ We provide clients with a competent and professional session for each appointment, addressing the client’s specific needs for that session.

~ Clients are NOT expected to undress during the session. Removal of shoes and socks is required for foot Reflexology appointments.

~ We are available for our clients Monday through Saturday by appointment only and clients may reach us by leaving a message.

~ We return calls within 24 hours unless on a specified break.

~ Clients are treated with respect and dignity.

~ We charge a fair price for our services.

~ We do not provide direct billing for our services.

~ We will provide a receipt for any service we provide upon request.

~ Appointments are confirmed the day before the appointment (you may be notified by email or text).

~ We perform services for which we are qualified (physically and emotionally) and able to do, and refer to appropriate specialists when work is not within our scope of practice and/or not in the client’s best interest.

~ We customize our sessions to meet each of our client’s specific needs.

~ We stay current with information and techniques by reading, receiving regular sessions of selfcare and by taking at least one workshop per year.

~ We respect all clients regardless of their age, gender, race, national origin, sexual orientation, religion, socio-economic status, body type, political affiliation, and state of health or personal habits.

~ Privacy and confidentiality are maintained at all times.

~ Our equipment and supplies are clean and safe.

~ Personal and professional boundaries are respected at all times.

CANCELLATION POLICY

My requirements of clients:

If cancellation is necessary, please give 4-hour notice or you will be charged 50 percent for the appointment. Emergency cancellations are determined at the practitioner’s discretion. Payment is expected at the time the service is rendered. 

What clients can expect from me:

If we need to cancel an appointment, we will do so within 10 hours whenever possible. If an emergency arises and we are not able to keep an appointment, we will work closely with client to find the best time for reschedule.