Residential Detox New Patient Form
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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:
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).
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.
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.
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
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.
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.
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:
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
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.
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 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.
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:
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.
Our “mission” is to provide integrated behavioral, psychiatric, and substance abuse services that are accessible, effective, safe, efficient, and appropriate to the needs of the consumers and his/her family.
1810 Moseri Road,
Decatur GA 30032
Toll-free: (855) 322-2850
(404) 289-8223 ext. 234or 224
Fax: (404) 286-7009
Newport Integrated Behavioral Healthcare, Inc is Accredited by Joint Commission