RESIDENTIAL DETOX NEW PATIENT FORMS - Newport Integrated Behavioral Health Care

Residential Detox New Patient Form

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NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE, INC

Triage-Adult Mental Health and Addictive Diseases

Consumer Basic Information

Today's Date*

MM slash DD slash YYYY

CID

Primary Count of Service Delivery: Dekalb

Medicaid/Medicare#

Payor/Funding Source

State

Contracted

Svcs

Other

Social Security#:*

Driver's License#

Consumer First Name:*

Consumer Last Name:*

Consumer Middle Name:

Date of Birth*

MM slash DD slash YYYY

Age*

Gender*

Male

Female

Trans-gendered

Gender Neutral

Marital Status:*

Single (Never married)

Separated

Divorced

Married

Domestic Partnership

Widowed

Race:

Black/African American

Asian

White/Caucasian

Multiracial

Native Hawaiian/Other

Pacific Island

Hispanic/Latino

Residential Address:

Homeless

Private Residence

Homeless, Not in Shelter

Home Address

Street City State / Province / Region ZIP / Postal Code Country

Veteran:

Yes

Number in Family:

Insurance ID#

Group#

Upload Front + Back of Insurance Card

Drop files here or

Max. file size: 256 MB, Max. files: 2.

Upload Photo ID Card

Drop files here or

Max. file size: 256 MB, Max. files: 1.

Highest Educational Level:

Monthly Income:

Primary Caregiver:

Spouse

Parents

Significant Other

Other Relatives

Friend

Other

English Proficiency

Proficient

Limited-Spanish Language

Limited-Primary Language

Other

Is Consumer Lawfully present in the United States?

Yes

N/A

Communication

No Impairment Noted

Single Words or Gestures

American Sign Language

Utilizes Language Technology

Referral Source:

GCAL

Walk-in

Hospital

JDFCS

Criminal Court

Family

School

Law Enforcement

Clergy

Other

Special Population:

Vision Impairment

Veteran

JHIV+

Hearing Impairment

Pregnant

JSSI/Disabled

JIV Drug User

None

Tobacco/Nicotine:

Have you ever used Tobacco/Nicotine products?

Yes

Smoker Status?

Current User

Former User

Age of First Use?

Legal: #of Arrests in Past 30 Days*

Current Legal Status:*

Probation

Parole

None

ADA Target Population: Does the adult have a diagnosis that qualifies as SPMI and meeting one or more of the criteria listed below:

Currently being served in or has a pending

Frequently readmitted to Psychiatric Inpatient Facility

Frequently seen in emergency rooms for behavioral health needs

Chronically homeless

Pending or recent release from jail or prison within 30-days.

Yes

N/A

SUBSTANCE ABUSE HISTORY:

Alcohol-Age of First Use

Frequency of Use:

Daily

Weekly

Monthly

Last Use:

Cocaine-Age of First Use

Frequency of Use:

Daily

Weekly

Monthly

Method of Use:

Snorting

Smoking

Other

Last Use:

Heroin-Age of First Us

Frequency of Use:

Daily

Weekly

Monthly

Method of Use:

Snorting

Smoking

Other

Last Use:

Pain Pills/Opioids-Age of First Use

Frequency of Use:

Daily

Weekly

Monthly

Method of Use:

Snorting

Smoking

Other

Last Use:

Cannabis-Age of First Use

Frequency of Use:

Daily

Weekly

Monthly

Method of Use:

Snorting

Smoking

Other

Last Use:

Other -Age of First Use

Frequency of Use:

Daily

Weekly

Monthly

Method of Use:

Snorting

Smoking

Other

Last Use:

Employment Status:

Unemployed

Student

Retired

Disabled

Inmate

Date of Last Employment:

MM slash DD slash YYYY

Employed As:

How many previous treatment episodes has the consumer received in any drug or alcohol program?

How many times has the consumer attended self help group in the past 30 days?

Employee Name:

Date

MM slash DD slash YYYY

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE, INC.
NEWPORT DETOX CENTER

Primary Diagnosis

DSM Code:

Referral Source:

Medical Diagnosis (if any):

Restrictions

ADA Special Needs:

Primary Care Physician:

Telephone No:

EMERGENCY CONTACT (Please sign release form)

Use the + to added additional contacts.

Name

Relationship

Home#

Address

Cell#

Additional Information:

FINANCIAL ACKNOWLEDGEMENT

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

I authorize Newport Integrated Behavioral Healthcare, Inc., or any of its providers, agents, contractors or business associates, to contact me (by any telephone numbers, email addresses or other contact points provided by me or on my behalf) by the use of any automatic dialing system, by pre-recorded forms of voice/ messaging systems, by electronic mail owned or used by the guarantor/responsible party, by text messages, by telephone or by cell phone for reasons related to the services I received at Newport Integrated Behavioral Healthcare, Inc or payment for the services I received at Newport Integrated Behavioral Healthcare, Inc., including but not limited to, debt collection purposes. I further understand and acknowledge that my consent in receiving the aforementioned communications is not required nor is it a preceding condition to receiving health care services at Newport Integrated Behavioral Healthcare, Inc.

I do not agree with the above statement and do not wish to be contacted except for clinical issues. By signing below, I acknowledge and agree that I have read or had this form read to me and I understand and agree to its contents.

By signing below, I acknowledge and agree that I have read or had this form read to me and I understand and agree to its contents.

PATIENT / REPRESENTATIVE

Date

MM slash DD slash YYYY

RELATIONSHIP TO PATIENT

Interpreter Signature

Note: If phone interpretation used, record interpreter ID #

RECEIPT OF NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I acknowledge receipt of the Notice of Privacy Practices from Newport Integrated Behavioral Healthcare, Inc. The Notice of Privacy Practices provides information about how Newport Integrated Behavioral Healthcare, Inc and staff members may use and disclose my health information. I have been encouraged to read the notice in full.

I understand that the Notice of Privacy Practices is subject to change. If Newport Integrated Behavioral Healthcare, Inc changes its notice, I may obtain a copy of the revised Notice on site and/or at Newport's website (www.nibhinc.com).

PATIENT / REPRESENTATIVE

Date

MM slash DD slash YYYY

RELATIONSHIP TO PATIENT

Interpreter Signature

Note: If phone interpretation used, record interpreter ID #

Newport Integrated Behavioral HealthCare, Inc.

Confidentiality of Alcohol and Drug Abuse Patient Record

The confidentiality of alcohol and drug abuse patient records maintained by the program is protected by Federal law and regulations. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcoholic or drug abuser, UNLESS:

The patient consents in writing
The disclosure is allowed by a court order: or
The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

Violation of the Federal law and regulations by a program is a crime. Suspected violations, may be reported to appropriate authorities in accordance with Federal regulations.

Federal law and regulations do not protect any information about a crime committed by, a patient either at the program or against any person who works for the program or about any threat to commit such a crime.

Federal law and regulations do not protect any information about suspected child abuse

or, neglect from being reported under State law to appropriate State or local authorities.

See 42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for Federal laws and 42 CRF Part 2 for Federal regulations.

(Approved by the Office of Management and Budget under Control No. 0930-0099).

Patient Signature

Date

MM slash DD slash YYYY

Patient Name

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE, INC.

Notice of Directory Listing

Newport Integrated Behavioral HealthCare, Inc. maintains a Facility Directory which includes information about patients to share with clergy. Information may also be shared with visitors who ask for information about you by name. The information that appears in the directory includes your name, your location within the Newport Integrated Behavioral HealthCare, Inc. facility, your general condition and your religious affiliation.

Please fill out the options below and return it to NIBH, INC. staff.

I have no objection to sharing my information in the NIBH, INC. Facility Directory.

I do not want the following information about me shown in the NIBH, INC. Facility Director.

Do not show anything about in the Directory.

Do not show my location in the Directory.

Do not show my general condition in the Directory.

Do not show my religious affiliation in the Directory.

Patient's Signature:

Print Patient's Full Name:

Date Signed:

MM slash DD slash YYYY

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE, INC.

Acknowledgement of Receipt

I received a copy of Newport Integrated Behavioral HealthCare, Inc. Notice of a Privacy Practice. I understand that if Newport Integrated Behavioral HealthCare, Inc. uses of my personal health information in a manner that is different than described by the Notice, Newport Integrated Behavioral HealthCare, Inc. must first get my permission in writing.

I am accepting this Notice of behalf of

Myself

Another person as his or her personal representative (parent, guardian, family member, etc.)

Signature of Patient/Personal Representative:

Print Name of Personal Representative (if applicable):

Date signed:

MM slash DD slash YYYY

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE, INC.

ADVANCED DIRECTIVES

Patient Name:

Patient SSN:

I am aware that all health maintenance and medical treatment contain an element of risk for an adverse reaction. During the course of my treatment, in the event that I lose consciousness, or become unable to respond in such a way as to pose a serious life threatening emergency, I will be transported to the nearest emergency care facility.

While at the Emergency Care Facility, if I am still unable to respond, I wish to have medical personnel apply all available technology and available medical procedures necessary to preserve my life.

I already have records of this decision, and you may obtain a copy.

Where:

Person/Organization:

Address:

Phone Number:

I am aware that I can change or revoke this directive at any time.

Patient's Signature

Date

MM slash DD slash YYYY

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE RULES & REGULATIONS CONTRACT

It is the policy of Newport Integrated Behavioral Healthcare, Inc., to provide a safe and therapeutic environment for all patients. Therefore, it is necessary for each patient to make a conscious effort to fully comply with all safety rules to prevent physical, psychological, and emotional abuse, and sexually related behavior.

PARTICIPATION: IN ALL GROUPS, SPIRITUALITY MEETINGS, & ALL OTHER MEETINGS IS MANDATORY ATTENDANCE-NO EXCEPTION, EXCEPT BY DIRECTOR/DOCTOR AND NURSE

WAKE-UP TIME: IS 6A.M. AND/OR WHEN AWAKENED BY THE NURSE

BEDTIME: IS 10:45P.M. SUNDAY THROUGH THURSDAY 12 MIDNIGHT FRIDAY AND SATURDAY

SMOKING: DESIGNATED HOURS ARE POSTED!! ABSOLUTLEY NO SMOKING IN THE BUILDING!!!

MEDICATIONS: ALL MEDICATIONS MUST BE APPROVED BY THE PHYSICIAN (DOCTOR) AND ARE ADMINISTERED BY THE NURSE. NO MEDICATION WILL BE KEPT BY THE CLIENT, EXCEPT THOSE ORDERED SPECIFICALLY BY THE DOCTOR. ALL MEDICATIONS PRESCRIBED OR OTC WILL BE TURNED OVER TO NURSE.

VALUABLES/PROPERTY: EACH PERSON IS RESPONSIBLE FOR HIS OWN

PROPERTY. WE ACCEPT NO RESPONSIBILITY FOR LOST/STOLEN PROPERTY

DRUG SCREEN/ROOM SEARCH: RANDOM DRUG SCREENS & ROOM SEARCHES MAY BE CONDUCTED AT ANYTIME AT THE DISCRETION OF STAFF FOR ALCOHOL DRUGS OR STOLEN ITEM WITH THE OCCUPANT PRESENT.

SICK CALL: ALL MEDICAL PROBLEMS WILL BE TOLD TO THE NURSE ON DUTY.

FOOD: NO FOOD OR DRINKS ARE TO BE BROUGHT FROM THE OUTSIDE-- NO FOOD OR DRINKS IN BEDROOMS!!

ARMBANDS: MUST BE WORN BY ALL CLIENTS AT ALL TIMES WHILE IN

TREATMENT.

CLOTHING: CLOTHING WILL BE WORN AT ALL TIMES! SUNGLASSES ARE NOT PERMITTED UNLESS THEY ARE PRESCRIBED!!!

ELECTRICAL EQUIPMENT: NO ELECTRICAL EQUIPMENT IS ALLOWED (WALKMAN'S, HAIR CLIPPERS, CELL PHONES, RADIOS, ETC.) IF YOU HAVE ANY OF THE ABOVE, THE NURSE WILL LOCK THEM UP UNTIL YOUR DISCHARGE.

TELEPHONE CALLS: ARE ARRANGED BY CASE MANAGER & SECRETARY ONLY

VISITORS: NO VISITORS DURING YOUR STAY IN DETOX. FAMILY

MEMBERS CAN DROP OFF CLOTHING, CIGARETTES, ETC. ALL ITEMS WILL

BE SEARCHED FOR CONTRABAND BY STAFF.

LAUNDRY: WILL BE DONE BY STAFF ONLY!! DESIGNATED DAYS ARE POSTED ON LAUNDRY ROOM DOOR!

SEXUAL ACTIVITIES: WILL NOT ENCOURAGE, ENGAGE, OR PROMOTE ANY TYPE OF SEXUAL ACTIVITIES THAT INCLUDE BUT NOT LIMITED TO: TOUCHING, HUGGING, KISSING, FLIRTING, STALKING, SEXUAL HARASSMENT, SEXUAL INTERCOURSE, AND RAPE.

DISCHARGEABLE SITUATION:

PHYSICAL VIOLENCE

ABUSIVE LANGUAGE

DRUG/ALCOHOL USE WHILE IN TREATMENT NON-COMPLIANCE WITH RULES AND REGULATIONS

FAILURE TO FOLLOW STAFF DIRECTIONS

SMOKING INSIDE BUILDING STEALING

NOT HAVING ARM BAND IDENTIFICATION ON AT ALL TIMES GAMBLING

POSSESSION OF ILLEGAL SUBSTANCES AND/OR WEAPONS LEAVING BUILDING WITHOUT PERMISSION

I HAVE READ AND FULLY UNDERSTAND THESE RULES AND REGULATIONS TO BE PART OF MY TREATMENT PLAN. I ALSO UNDERSTAND THAT COMPLIANCE WITH THESE RULES AND REGULATIONS WILL INSURE A DEGREE OF GROWTH AND CHANGE WHILE IN THE PROGRAM.

NON-COMPLIANCE WITH THESE RULES AND REGULATIONS COULD LEAD TO IMMEDIATE DISCHARGE FROM THIS PROGRAM AND REPORTED TO PROPER AUTHORITIES WHEN APPROPRIATE.

PATIENT NAME:

Date

MM slash DD slash YYYY

Patient's Signature

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE, INC.

NOTIFICATION POLICY:

Policy: It is the policy of NIBH, INC. to provide, promote positive behavior and protect the safety of service to patients, families and staff. Under no circumstances, does NIBH, Inc. uses restrictive behavior support interventions, such as manual restraints, mechanical restraints, or locked seclusion.

Purpose: To ensure that a safe environment, appropriate behavioral support and management practices are provided for patients, families and staff. To ensure that NIBH, Inc. do not use restrictive behavior management interventions.

Procedures: If the patient is unmanageable and display a threat to operations, and/or delivery

of services, to him and/or others, Please follow these behavior support procedures:

All staff is responsible for preventing the need for behavior management interventions.
All staff is responsible for identifying and reporting any inappropriate behaviors during his/her tour of duty to the treatment team, security officer and safety Officer.
If NIBH, Inc. is unable to manage the patient's behavior, and he/she poses a major threat to the operations and delivery of services, the treatment team (nurse, counselor, physician) and security officer are responsible for assessing patient's inappropriate behavior and call 911. The local Sheriff's office may also be called if additional assistance if needed. The patient is removed from Newport Integrated Behavioral Healthcare premises by the law enforcement officers. Under no circumstances will any staff use manual restraint, mechanical restraints, or locked seclusion to manage the patient, or any persons served.
The attending treatment team member (nurse, counselor, or Physician) is responsible for completing the critical incident report, and submit to the Medical Director/Executive Director for immediate review, additional instructions, investigational action and follow-up. Copies of the critical incident report will be forwarded to the appropriate authorities, local and state.
Each patient, or legal guardian must sign this behavioral support and management Notification Policy & Procedures during intake/admission, and filed in the patient's chart (See attachment)

Patient or legal Guardian name

I have read and understood the above policy and procedures, and will comply with the behavioral rules and regulations set forth by Newport Integrated Behavioral Healthcare, Inc., in order to provide a safe treatment environment for me and others.

Patient's signature:

Date

MM slash DD slash YYYY

NEWPORT DETOX CENTER, INC

MEDICAL AUTHORIZATION

I give permission for the Program nurse/staff to administer medication as prescribed by doctor.

I agree to provide at least a two weck supply of my own prescribed medication prescribed

by other doctors.

I agree to obtain medical services for myself for illnesses/conditions which interfere with

the detoxification.

I give the Program's staff permission to administer first aid procedures to myself.

I give the Program's staff permission to release any medical/physical information to a physician in an emergency situation.

TREATMENT:

I hereby grant permissions to NEWPORT DETOX CENTER to provide services to me. I agree to participate in the treatment plan as recommended.

I hereby give consent to take photographs, vidcos, and audio tapes and interviews of me for departmental use only.

I ACCEPT

I DO NOT ACCEPT

PAYMENT

I hereby authorize the release of any relevant information to Medicaid/Medicare or other insurance companies to facilitate reimbursement to NEWPORT DETOX CENTER, for services received. Regulations pertaining to Medicaid assignment of benefits apply.

I accept responsibility for foes not covered by private insurance or other third party payers. I understand that any resulting fees will be based on a sliding fee scale. I may request a financial review of my account. If I fail to comply with my payment obligations, my account will be referred to a collection agency for legal action.

I have read and understand the above statements, and agree to the above.

Client's Signature:

Date

MM slash DD slash YYYY

Client's Name

Date

MM slash DD slash YYYY

Client's ID No:

Date

MM slash DD slash YYYY

Patient Bill of Rights

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

Date

MM slash DD slash YYYY

Patient/Guardian or Parent of a Minor Signature

NEWPORT INATED BEHAVIORAL HEALT TREATMENT INFORMED CONSENT

You are on admission at Newport Integrated Behavioral Healthcare for a detoxification process. Detoxification process involves administration of some medications that are normally used to treat withdrawal symptoms associated with sudden cessation of substance use. These medications include drugs that are classified as either benzodiazepines, or barbiturates. 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 detoxification. 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 also assist you in the administration of other medications that you may have been taking for concomitant medical or psychiatric illnesses. In these situations you will only be allowed to take these medications under the supervision of the nursing staff on duty.

It is your duty as a patient to:

Cooperate with the nursing staff in the safe detoxification process
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
Risk of treatment includes but not limited to Change in People, Places, and Things.
Benefit of treatment includes Abstinence and having a Relapse Prevention 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.

I do hereby attest that I fully understand the above information, which has also been explained to me by the medical staff of NIBH.

I authorize the medical staff to proceed with the detoxification process.

Patient's Signature

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE, INC

SUBSTANCE ABUSE HISTORY:

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE, INC.
NEWPORT DETOX CENTER

EMERGENCY CONTACT (Please sign release form)

FINANCIAL ACKNOWLEDGEMENT

RECEIPT OF NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

Newport Integrated Behavioral HealthCare, Inc.

Confidentiality of Alcohol and Drug Abuse Patient Record

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE, INC.

Notice of Directory Listing

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE, INC.

Acknowledgement of Receipt

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE, INC.

ADVANCED DIRECTIVES

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE RULES & REGULATIONS CONTRACT

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE, INC.

NOTIFICATION POLICY:

NEWPORT DETOX CENTER, INC

MEDICAL AUTHORIZATION

Patient Bill of Rights

NEWPORT INATED BEHAVIORAL HEALT TREATMENT INFORMED CONSENT

Patient forms

Contact Us

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE, INC

SUBSTANCE ABUSE HISTORY:

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE, INC. NEWPORT DETOX CENTER

EMERGENCY CONTACT (Please sign release form)

FINANCIAL ACKNOWLEDGEMENT

RECEIPT OF NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

Newport Integrated Behavioral HealthCare, Inc.

Confidentiality of Alcohol and Drug Abuse Patient Record

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE, INC.

Notice of Directory Listing

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE, INC.

Acknowledgement of Receipt

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE, INC.

ADVANCED DIRECTIVES

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE RULES & REGULATIONS CONTRACT

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE, INC.

NOTIFICATION POLICY:

NEWPORT DETOX CENTER, INC

MEDICAL AUTHORIZATION

Patient Bill of Rights

NEWPORT INATED BEHAVIORAL HEALT TREATMENT INFORMED CONSENT

Patient forms

Contact Us

NEWPORT INTEGRATED BEHAVIORAL HEALTHCARE, INC.
NEWPORT DETOX CENTER