Healthcare Recovery Center Document

Healthcare Recovery Center Document

Patient Information

Patient Name:    Date of Birth:    Admission Date:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Medical & Behavioral History

Consent for Assessment and Treatment

I, the undersigned patient, authorize the Healthcare Recovery Center and its licensed staff to perform a comprehensive assessment and to provide medically necessary treatment including but not limited to medically supervised detoxification, medication-assisted treatment, psychotropic medication administration, individual and group therapy, case management, and discharge planning. I understand that treatment may include clinical assessments, laboratory testing, and medication management as appropriate.

I acknowledge that treatment carries risks and potential side effects including allergic reaction, medication side effects, withdrawal complications, and possible lack of therapeutic benefit. I have been given the opportunity to ask questions and receive answers about the nature of the assessment and proposed treatment, reasonable alternatives, and potential risks. I understand that I may withdraw consent at any time except to the extent that action has already been taken in reliance on this consent.

By checking the box below I give informed consent to receive the services described above.

I consent to assessment and treatment as described

Authorization for Release of Medical Information

I authorize the Healthcare Recovery Center to release and obtain my protected health information related to treatment, billing, and coordination of care to/from the persons and organizations named below for the purpose stated. This authorization includes substance use treatment records and behavioral health information to the extent permitted by applicable law.

This authorization expires on:    I understand that I may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance upon it.

I authorize release/exchange of my health information as described above

Financial Responsibility & Assignment of Benefits

I accept financial responsibility for services rendered by the Healthcare Recovery Center and agree to pay any co-payments, deductibles, or charges not covered by my insurer. I authorize assignment of insurance benefits to the provider where permitted for the payment of services rendered to me.

I authorize assignment of benefits and accept financial responsibility

Confidentiality, HIPAA & Limits of Confidentiality

The Healthcare Recovery Center maintains the confidentiality of patient records consistent with applicable law. Exceptions include: suspected child or elder abuse, imminent risk of harm to self or others, court order, or other disclosures required by law. I understand that disclosure of substance use disorder treatment records is subject to special protections and will only occur with my authorization except as permitted by law.

I acknowledge receipt of the Center's Notice of Privacy Practices and understand my rights regarding protected health information

Emergency Medical Treatment Authorization

In the event of a medical emergency, I authorize the Healthcare Recovery Center and its staff to arrange and consent to emergency medical treatment and transportation on my behalf if I am unable to do so. I understand the Center will make reasonable efforts to notify my emergency contact.

I authorize emergency medical treatment and transportation as needed

Patient Certification

I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I have read and understand this document. I understand the nature of the proposed assessment and treatment, the risks and benefits, and my rights to revoke authorizations as described. I consent voluntarily to the services and authorizations indicated on this form.

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