CURRENT MEDICAL PROBLEMS

IF YOU ARE BEING TREATED FOR ANY OTHER ILLNESSES OR MEDICAL PROBLEMS BY ANOTHER PHYSICIAN, PLEASE DESCRIBE THE PROBLEMS & INDICATE THE NAME OF THE PHYSICIAN TREATING YOU. ILLNESS OR MEDICAL PROBLEMS PHYSICIANS TREATING YOU

ILLNESS AND MEDICAL PROBLEMS

PLEASE MARK WITH A (X) ANY OF THE FOLLOWING ILLNESSES & MEDICAL PROBLEMS YOU HAVE OR HAVE HAD. ALSO INDICATE THE YEAR WHEN EACH STARTED. IF YOU ARE NOT CERTAIN WHEN THE ILLNESS STARTED, WRITE DOWN AN APPROXIMATE YEAR.

Person recording list of medications:

Your rights include:

1. Right to a humane treatment or habilitation environment that affords reasonable protection from harm, exploitation, and coercion;

2. Right to be free from physical and verbal abuse;

3. Right to be free from the use of physical restraints and seclusion unless it is determined that there are no less restrictive methods of controlling behavior to reasonably insure the safety of the client and other persons:

4. Right to be informed about plan of treatment and to participate in the planning, as able;

5. Right to be promptly and fully informed of any changes in the plan of treatment;

6. Right to accept or refuse treatment, unless it is determined through established authorized legal processes that the client is un-able to care for himself or is dangerous to himself;

7. Right to be fully informed of the charges for treatment;

10. Right to converse privately, have convenient and reasonable access to the telephone and mails, and to see visitors, unless denial is necessary for treatment and the reasons are documented in the client's treatment plan; 11. Right to be informed of the program's complaint policy and procedures and the right to submit complaints without fear of discrimination or retaliation and to have them investigated by the program within a reasonable period of time;

12. Right to have access to their own client records and to obtain necessary copies when needed;

13. Right to receive a written notice of the address and telephone number of that state licensing authority, i.e. the department, which further explains the responsibilities of licensing the program and investigating client complaints which appear to violate licensing rules;

14. Right to obtain a copy of the program's most recent completed report of licensing inspection from the program upon written request. The program is not required to release a report until the program has had the opportunity to file a written plan of correction for the violations as provided for in these rules; and (b) Such policies and procedures shall also include provisions for clients and others to present complaints, either orally or in writing, and to have their complaints addressed and resolved as appropriate in a timely manner.

If you feel your rights have been violated, you may contact any of the agencies listed below:

  1. The State of Georgia Department of Behavioral Health & Developmental Disabilities, office of External Affairs, (404) 657-5964 Or

2. Dept of Community Health Facility Regulations, (404) 657-5726 or 5728 and 1800-878- 6442-Address: 2 Peachtree St., Atlanta, GA 30303 Or

3. Georgia Advocacy Office in Atlanta, GA. (404) 885-1234, or 1800-537-2329 Or

4. Governor's Office of Disability Services Ombudsman, (404) 656-4261

IMPORTANT: DO NOT SIGN THIS FORM WITHOUT READING AND UNDERSTANDING ITS CONTENTS.

In consideration of services provided by Newport Integrated Behavioral Healthcare, Inc (NIBH), the Patient or undersigned representative acting on behalf of the Patient agrees and consents to the following:

1. CONSENT FOR TREATMENT: I request and voluntarily give consent to my physician and other clinicians, including nurses, counselors, nurse techs, medical residents, who may attend me during this present period of treatment, their associates and assistants, Newport Integrated Behavioral Healthcare, Inc and its agents and employees and students under the direction thereof, to provide and perform evaluation, treatment, consultation and/or other care, services and supplies as are considered advisable by my physician for my health and well being. I recognize that certain clinical staff furnishing services may be independent contractors and not employees or agents of Newport Integrated Behavioral Healthcare, Inc. I understand that services will be provided or supervised by appropriately staff within the scope of their license, certification and training. I acknowledge that no representations, warranties or guarantees as to results or cures have been made to me.

2. RELEASE OF INFORMATION FOR PAYMENT OF SERVICES AND CONTINUITY OF CARE: I understand that Newport Integrated Behavioral Healthcare, Inc and my physician(s) will release any and all information regarding diagnosis, treatment and prognosis with respect to any physical or psychiatric condition-including treatment for alcohol or drug abuse-for which I am being treated at Newport, to any insurance company, employer, school, sponsored payer and/or third party payers, or representative providing coverage for this admission. Information will also be released to healthcare providers for continuity of care. I understand that federal law and regulations do not protect any information about a crime committed by a patient at Newport Integrated Behavioral Healthcare, Inc or against any person who works for Newport Integrated Behavioral Healthcare, Inc or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected abuse or neglect from being reported under state law to appropriate state or local authorities.

3. ASSIGNMENT OF BENEFITS: In consideration for services rendered or to be rendered to me by or through Newport Integrated Behavioral Healthcare, Inc, I hereby assign to Newport Integrated Behavioral Healthcare, Inc all insurance benefits, including Medicare, covering this present period of treatment. I understand that regardless of this assignment, I remain primarily responsible to Newport Integrated Behavioral Healthcare, Inc for all actual charges related to this present period of treatment. It is further agreed that any self pay credit balance resulting from payment of the insurance benefits may be applied to any other account owed to Newport Integrated Behavioral Healthcare, Inc by me or my family.

4. FINANCIAL AGREEMENT: I will make every effort to actively assist Newport Integrated Behavioral Healthcare, Inc with securing payment for services rendered for which I am liable. If I am the parent/guardian of a minor patient, I understand that unless addressed in my third-party payer agreements, I am financially responsible for all services rendered, and that the parent who authorizes treatment will be responsible for any balance due. I understand that Newport Integrated Behavioral Healthcare, Inc submits claims to insurance carriers to assist its patients and that I am responsible for the balance owed at any time unless other arrangements have been made. I understand that my third-party payer may require me to obtain prior/post-authorization in order to cover services. I understand that if I do not provide sufficient and timely information and releases of information for Newport Integrated Behavioral Healthcare, Inc to process insurance claims, I will be responsible to pay Newport Integrated Behavioral Healthcare, Inc and standard fees. I agree to pay any collection costs and/or legal fees incurred by Newport Integrated Behavioral Healthcare, Inc in attempts to collect the balance owed on my account. Consent to receiving auto-dialed and or artificial or pre-recorded message calls to me cellular or and line telephones.

5. HEALTHCARE PRACTITIONERS IN TRAINING: Patient recognizes that among those who may attend Patient at Newport are medical, nursing and other health care personnel who are in training and who, unless specifically requested otherwise, may be present and participate in patient care activities as part of their clinical education.

6. PERSONAL VALUABLES AND PROPERTY DAMAGE: Patient acknowledges that Patient has received a copy of Patient Rights and has verified the information utilized during this registration and confirms its accuracy. Newport shall not be liable for the loss or damage of any personal belongings, including but not limited to money, cell phones, laptops, electronic devices, jewelry, hearing aids, computers or dentures, unless properly secured and placed within the facility Locker.

7. CONSENT TO PHOTOGRAPH: I consent to have my photograph taken and used for identification during my treatment, and then maintained in my medical record, as requested by Newport Integrated Behavioral Healthcare, Inc.

8. WEAPONS/CONTRABAND SEARCH: I understand that Newport Integrated Behavioral Healthcare, Inc policy prohibits the introduction of firearms and weapons on facility property by other than Sworn Police Officers. Any weapon now in my possession will immediately be removed for the facility and Dekalb Police Officers will be called immediately. I understand that based on certain criteria for the safety of all staff and patients, if I have certain conditions or behaviors I may have my person and belongings searched.

9. AUTHORIZATION TO RELEASE INFORMATION: Newport is authorized to release information contained in the patient record. The information authorized to be released shall include, but is not limited to, infectious or contagious disease information, including HIV or AIDS- related evaluations, diagnosis or treatment, information about drug or alcohol abuse or treatment of same and/or psychiatric or psychological information. Patient waives any privilege pertaining to such confidential information. Newport, its agents and employees are hereby released from any and all liabilities, responsibilities, damages, claims and expenses arising from the release of information as authorized above. Reasons for releasing a Patient's record include, but are not limited to, insurance company(s), their agents or other third party payor and/or government or social service agencies which may or will pay for any part of he behavioral health expenses incurred or authorized by representatives of Newport, as mandated by law, or to alternate care providers, including community agencies and services, as ordered by Patient's physician or as requested by Patient or Patient's family for post- care. PATIENT ACKNOWLEDGES AND AGREES THAT PATIENT'S RECORDS WILL BE AVAILABLE TO ALL NEWPORT PROVIDERS, AND TO REFERRING PROVIDERS IN COMPLIANCE WITH THE PROVISIONS OF MEANINGFUL USE.

10. PATIENT SURVEY: Patient authorizes Newport and/or its authorized representative to contact Patient after discharge for the purpose of conducting patient satisfaction surveys and other studies.

11. CONSENT TIMEFRAME AND APPLICABILITY: The above consents are applicable to all residential and outpatient based services, as well as all physician office based services. With respect to residential based services. The consents shall be valid for a term of one (1) year from the date of signature below.

12. KNOW YOUU INSURANCE AND YOUR PAYMENT RESPONSIBILITY: In order to accommodate the needs and requests of our patients we have enrolled in numerous manage care insurance programs. While we are pleased to be able to provide this services to you, it is extremely difficult for us to keep track of all the individual requirements of the plans. Each one has different stipulations regarding how often services may be rendered and even more importantly, where those services may be performed. Even within the same insurance company the plan may differ depending upon what type of contract your employer has negotiated. Manage care insurance companies are not prompt with their payments. Some companies pay in two weeks while others may take six weeks. Please follow up with insurance to ensure claim is paid timely. COORDINATION OF BENEFITS IS THE INSURED'S RESPONSIBILITY. Providing quality medical care for our patients is our primary concem. We are more than willing to provide your care within your insurance contract guidelines if you let us know at each time of service what those guidelines are. Unfortunately, if you do not inform us of any special requirements in your contract and we subsequently order services, such as lab work that are not covered, we or the selected provider will have no choice but to bill you directly for those non-covered charges. Payment for those charges is then your responsibility. With your cooperation and help, you should be able to receive all of the benefits offered to you by your chosen insurance plan, and we will be able to concentrate on caring for your medical needs. ALL MEDICARE PART B Patients with no other coordinating benefits are responsible for 20% of all services rendered according to Medicare guidelines patient responsibility. (Initial Here)

13. DISCLOSURE OF PROTECTED HEALTH INFORMATION: Newport Integrated Behavioral Healthcare, Inc NOTICE OF PRIVACY PRACTICES provides a more complete description of such uses and disclosures. I have the right to review the notice if privacy practices prior to signing this consent. Newport Integrated Behavioral Healthcare, Inc reserves the right to revise the Notice of Privacy Practices at any time. A revised Notice of Privacy practices may be obtained by forwarding a written request to: Newport Integrated Behavioral Healthcare, Inc 1810 Moseri Rd, Decatur GA 30032.  

I have read and understand the above guidelines. I understand that charges deemed non-covered by my insurance and/or any charges applied to my deductible or deemed as coinsurance company are my responsibility. I understand that late/billing fees $10 per month are applied to my account beginning 60 days after charges are turned over to patient responsibility and are to be paid e. I understand that Newport Integrated Behavioral Healthcare, Inc utilizes the services of a collection agency when deemed necessary.

I may revoke my consent in writing, except to the extent that the practice has already made disclosures in reliance upon prior consent, It I do not sign this consent, or later revoke it, Newport Integrated Behavioral Healthcare, Inc may decline to provide treatment to me.

  Validity of Form Patient acknowledges that a copy, or an electronic version of this document may be used in place of and is as valid as the original. Patient understands that the Healthcare Professionals participating in the Patient's care will rely on Patient's documented medical history, as well as other information obtained from Patient, Patient's family or others having knowledge about Patient, in determining whether to perform or recommend the Procedures; therefore, Patient agrees to provide accurate and complete information about Patient's medical history and conditions. Patient confirms that Patient has read and understood and accepted the terms of this document and the undersigned is the Patient, the Patient's legal representative or is duly authorized by the Patient as the Patient's general agent to execute the above and accept its terms.

This consent form is to document that I give my permission and consent to Clinician and the other employees/contractors of Newport Integrated Belravioral Healthcare, Inc. to provide treatment to my child/grandchild or self. I understand that because of the counseling or therapy, I may experience emotional strain, feel worse during treatment, and make life changes that could be distressing.

I understand that this Clinician might or might not be providing an emergency service and I have been informed of whom to call in emergency or during weekend and evening hours. I understand that regular attendante will produce the maximum benefits but I or we am/are free to discontinue treatment at any time. If I decide to do so will notify the Clinician at least two weeks in advance so my st that effective planning for continued care could be implemented.

I understand that conversations with the Clinician will almost always be confidential with the exception of situations mentioned in client handout (Available at the Front Desk). I further understand that Clinician, by law, must report actual or suspected child or elder abuse to the appropriate authorities. In addition, the Clinician has a legai responsibility to protect anyone I may threaten with violence, harmful or dangerous actions (including those to myself) and may break confidentiality of communication if such a situation arises. I understand that the Clinician will make reasonably efforts to resolve these situations before breaking confidentiality.

I understand that I might be required to visit a licensed psychiatrist for an initial assessment and I agree with my Clinician scheduling and appointment for me. I also give consent to Newport Integrated Behavioral Healthcare, inc. to submit an appeal on my behalf, in case the authorization for services is denied by my Insurance Company. It is the client's responsibility to keep their Insurance current and if it lapses during treatment fees may be assessed on a sliding fee scale, or fee- for-service, and/or Insurance contracted rate. I know of no reason that I should not undertake this therapy and I agree to participate fully or voluntarily. I have read and understood the following forms and that I agree to abide by its terms during our professional relationship:

1. Introduction of our company and services
2. Client's Bill of Rights
3. Limits of Confidentiality
4. HIPAA Form
5. Client Rights Complaint Form
6. Choice of Provider
7. Consent to Treatment
8. Orientation of Advocacy
9. Orientation of Mental Health Advance Dir

10. Treatment Courses
11. Services that will be provided
12. Right to Ethical Treatment BY SIGNING THIS FORM I AM ATESTING TO THE FACT I AM LAWFULLY IN THE U.S.

I voluntarily refuse the treatment of my child/grandchild and I am aware of legal and other implications related to my decision. I understand that the client needs to go through the new referral process if he or she is to re-enter the program

ASSIGNMENT OF BENEFITS: In consideration of the services provided at Newport Integrated Behavioral HC, I hereby assign and transfer to the Facility and other clinical providers all behavioral and medical provider benefits payable under my insurance policies or benefit plans. I hereby assign and transfer all related rights and remedies due under the insurance policies or benefit plans that I have identified or will identify in connection with all services rendered, including but not limited to all rights and remedies pursuant to applicable state, federal and ERISA regulation. I hereby assign and transfer all rights to the Newport and other medical providers applicable under ERISA, federal or state regulation to pursue any benefit denial, limitation of coverage or request for an administrative review of fiduciary duties involving administration of benefits by the U. S. Dept of Labor, the Department of Community Health or the Department of Insurance. I authorize and direct the insurance company to pay all such benefits to the Newport Integrated Behavioral Healthcare and appropriate clinical providers. I understand that assignment does not relieve me of any responsibility I may have for payment of charges not paid by the insurance company, unless otherwise provided by the

PRECERTIFICATION: I understand that my insurance policy may require compliance with a utilization review program to make certain that health care benefit funds are terms of an agreement between the insurance company and the Facility. expended when justified. I understand that it is the utilization review program's responsibility to review proposed elective admissions and anticipated courses of treatment. I understand that if the utilization review program determines that admission is necessary and appropriate and issues certification, the benefits of my health plan will be made available to me in accordance with the terms of my policy. However, if certification is denied, health care benefits may be withheld. I understand that precertification may be the responsibility of the patient or financially responsible party and his or her physician. I understand that Newport Integrated Behavioral Healthcare, Inc is willing to admit as requested by my psychiatrist. I also understand that I may be financially responsible for all residential charges incurred as a result of admission should the utilization review program refuse to certify that the admission is appropriate, or should the certification effort occur too late to be valid. I understand that to protect myself from unnecessary personal financial losses, I must provide insurance coverage at time of registration, review my obligations with my insurance company, utilization review program, and personal physician without delay.

ABOUT YOUR BILLING: Facility and Provider-Based Services- A bill will be received for the professional component of treatment. Although Newport Integrated Behavioral Healthcare may be a provider in an insurance network, the physician or professional service provider may or may not be a covered provider of service. If the care received is outpatient care, the insurance carrier will process the claim(s) on an outpatient basis. Outpatient services may require co-insurance, deductible and/or co-pay, depending on insurance policy benefits.

FINANCIAL RESPONSIBILITY: Payment in full is expected at the time services are received. Accounts more than 30 days past due will accrue percent a year. This interest does not apply to deductibles/copayments of Medicare/Medicaid or other govemmental programs. (Accounts under an agreed alternate interest at the rate of 8 payment contract will not be considered past due, provided the plan is accepted in writing.) Insured patients are required to pay identified co-pay, unsatisfied deductible, and estimated co-insurance prior to any elective services unless alternate arrangements are made. Uninsured patients are required to make payment in full prior to any elective services unless alternate arrangements are made. This provision does not apply, and payment will not be requested, prior to emergency screening and stabilizing treatment as required by federal law.

GOOD FAITH ESTIMATE: Under the law, NIBH need to give patients who do not have insurance or who are not using insurance an estimare of the bill for medical items and services. You have the right to receive a Good Faith Estimate in writing at least 1 business day before your scheduled appointment for the total expected cost of any non- emergency items or service. This includes related cost like medical tests, prescription drugs, equipment, and inpatient/hospital fees. In addition, you can also request a Good Faith Estimate before you schedule an appointment. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cmc.gov/nosurprise or call 1-800-985-3059

Where

You are on receiving treatment at Newport Integrated Behavioral Healthcare for Behavioral Health Services with includes Substance Abuse and/or Mental Health Services. Behavioral Health Services process involves providing diagnosis and possible prescription of some medications that are normally used to treat mood disorder or severe and persistent mental health disorder. These medications include drugs that are classified as psychotropics. They are medications that are approved by the Drug Food and Administration department of the United State for this purpose. You will be notified which particular medication is being used for your treatment. The risks and benefits associated with the medication will also be explained to you by the doctor and our trained nurses. You may also request additional information from the dispensing pharmacy, available literatures in our library and on the internet. We will also provide information regarding other treatment options. In addition, we will collaborate with your medical providers for medications that you may be taking for concomitant medical illnesses. It is your duty as a patient to:

a) Cooperate with the clinical staff in the safe treatment process
b) Inform the physician of any known pre-existing medical condition they may potentially be endangered by the use of the above medications e.g. pregnancy
c) Risk of treatment includes but not limited to Change in People, Places, and Things.
d) Benefit of treatment includes Abstinence, symptom management and having a Relapse Prevention Plan/Safety Plan.

We also will like to inform you that you are under no obligation to take the medications prescribed NIBH physician and you may stop at any time. Should you decide to do so, we will advise that you inform the physician before you do so.