Admission Face Sheet

HIPAA INFORMATION AND CONSENT FORM

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete test is posted in the office.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal exchange of information necessary to provide you with medical services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov
We Have Adopted The Following Policies:

Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.

It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.

The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.

You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.

You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.

Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.

We agree to provide patients with access to their records in accordance with state and federal laws.

We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.

You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request. Date Format: MM slash DD slash YYYY

I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force form this time forward.

I Agree to the terms and conditions. The above information provided is accurate to the best of my abilityConsent

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability

ADMISSIONS AGREEMENT

Bella Nirvana Center is a 24-hour residential, incidental medical services, substance use disorder program. I consent to voluntarily participate in the Bella Nirvana Center substance use disorder program, as discussed with and recommended by my treating practitioner ["Treatment Program"]. The treatment program will include detoxification monitoring services, with a minimum of every 30 minutes during the first 72 hours after admission. I understand that I am not obligated to remain at Bella Nirvana Center. I have the right to refuse any and all services and to have the consequences of such refusal fully explained to me. I agree to comply with the treatment requirements for incidental medical services: a medical history, physical examination, drug and alcohol screens, tests, fees, recommended laboratory tests, and detox medications (if needed).

I acknowledge that payment for my Treatment Program as described in my Financial Agreement, including the amounts assessed for any services provided at and my payment schedule (if applicable).

I understand that my admission/treatment is on a voluntary basis. I may terminate the agreement at any time, however financial penalties may apply. I have been given detailed information regarding my financial obligations and I understand that fees assessed for the Bella Nirvana Center services I will be provided.

I am aware I will receive a copy of the Bella Nirvana Center's Resident Handbook which contains program rules and regulations. I understand that I will participate in a formal orientation program within 24 hours following my admission. I will be acknowledging by my signature that staff has reviewed the handbook with me. On my admission day, program staff will provide me with an overview of the community guidelines .

I am aware I will receive a copy of the Resident schedule and I understand the activities/programming for which I am being asked to participate. At Bella Nirvana Center, we understand that during the first 48 hours of treatment you are not expected to fully participate, therefore, full participation will be encouraged and expected thereafter.

Strict confidentiality of my Resident information is observed. In accordance with Title 9, Chapter 4, Section 10569, of the California Code of Regulations each person receiving services from a residential alcoholism or drug abuse recovery or treatment facility shall have rights which include, but are not limited to, the following: The right to confidentiality as provided for in Title 42, Section 2.1 through 2.67-1, Code of Federal Regulations.

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability.

I. CONSENT TO ADMISSION

The Resident acknowledges that Bella Nirvana Center staff routinely monitors client's rooms to ensure the safety of the Resident and the community. The individual acknowledges that clients will open any mail packages in the presence of staff. The Resident authorizes staff from Bella Nirvana Center to search the personal belongings of the Resident at admission and discharge, whenever new items are drop off at the premises, when a Resident returns from an outing or activity and when it is reasonably believed that Resident may be or is in possession of an item or items which may be dangerous to the client's health or others. If any are found, it is understood that they will be maintained in a secure place and returned to the Resident at discharge, unless otherwise therapeutically indicated by the administration. Illegal substances or unidentified drugs will be properly discarded by two staff members of Bella Nirvana Center.

The individual consents to the taking of photograph(s) for the purpose of identification. This photograph(s) may be permanently retained in the client's treatment record. The individual releases Bella Nirvana Center from any liability for the loss or damage of personal property and money kept in the client's room during the individual's stay. Furthermore, it is understood and agreed that Bella Nirvana Center shall not be responsible for loss or damage to any monetary, personal valuables or other articles unless deposited for safekeeping in the office room.

The individual acknowledges that to promote the safety of clients and visitors, as well as the security of its premises, Bella Nirvana Center has the right to conduct video surveillance of any portion of its premises at any time. Video cameras will be positioned in appropriate places within and around the premises to the exception to this includes private areas such as restrooms, showers and Resident rooms.

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability

II. CONSENT FOR TREATMENT

The undersigned authorizes Bella Nirvana Center and its staff to render to (client) all customary care, therapy, treatment, tests and procedures considered advisable, including treatment and transportation to another facility, if necessary. Further consent is also given for any diagnostic procedures, recreational activity, therapy, and other treatment offered by Bella Nirvana Center, including but not limited to services provided by other healthcare professionals to the client.

The Resident understands that they will be asked to give a random urinalysis, a breathalyzer, and/or saliva sample upon admission and at any time. A staff member will monitor the test, will obtain a gown search with the Resident upon admission, and every time the Resident goes on a therapeutic pass.

The Resident agrees that they will be on a five day blackout period to insure a stronger stabilization period in the early phase of treatment. The stabilization period (“no contact”) includes no phone time, outside activities, and visitation.

The Resident attests that they have no other medications on their possessions, other than as specified in the client's plan of treatment, prescribed by the client's current physician, and agrees that all said medications will be stored by Bella Nirvana Center. All medication will be self administered under the supervision of Bella Nirvana Staff as a Resident during their residence at Bella Nirvana. Clients will be responsible for medications not covered by their insurance. The Resident understands that whenever discharged from a medical transfer, that we will not return controlled substances, including narcotics, and that these will be destroyed. The Resident understands that all controlled medications brought into Bella Nirvana Center not specified in the client's plan of care or prescribed by the individual's current physician working with Bella Nirvana Center will be destroyed and not returned to the client. Bella Nirvana Center will provide over the counter medications available to clients.

The Resident agrees that Bella Nirvana Center will not be responsible for the individual's safety or care if the individual decides to leave the premises without finishing the entire program. Bella Nirvana Center will not take responsibility from any loss or injury which may occur as a result of leaving Against Staff Advice (ASA).

The individual understands that the use of reasonable restraint and/or confinement may be necessary if severity of symptoms or behaviors warrant, protecting the Resident from harming himself or others, or destroying property. The individual understands and agrees to protect Bella Nirvana Center, its staff physician, or other mental health professionals, from any loss due to injury that may occur as a result of such restraint and other/or confinement.

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability.

III. PROGRAM SERVICES

We will provide the following services:

Healthy three Meals per day, juices and snacks.

Laundry Facilities.

Linens and bath towels.

Monitoring of resident’s safety, health issues and progress during the detoxification and/or treatment process.

Intake health screening using the Client Health Questionnaire and Initial Screening Questions (DHCS 5103). Screening and assessment(s) performed by medical, psychiatric, and/or clinical professionals. For any non-emergency medical needs that arise outside the scope of the Treatment Program while I am a resident at Bella Nirvana Center, I agree to consult with Bella Nirvana Center staff to make individual, separate arrangements with the provider of the medical services. I understand that Bella Nirvana Center will neither directly pay for, nor bill for services given by an outside provider, pharmacy or other external medical supplier, and I am responsible for payment of all services outside the scope of my Treatment Program. Off-site transportation will be arranged in consultation with Bella Nirvana Center staff and my treating provider in accordance with my Treatment Program. I authorize Bella Nirvana Center to transport me or arrange for transportation to an appropriate medical facility to receive emergency medical treatment, if necessary.

Drug and alcohol screening.

Additional medical referrals will be provided as needed or requested for those services not provided by our facility; any general or primary care referrals will be direction to an independent physician; it is the responsibility of the resident to pay the physician directly for any medical services.

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability.

IV. ACTIVITIES EXPECTED OF RESIDENTS

Having voluntarily entered Bella Nirvana Center, regardless of the referral source that brings me here, I agree to the following:

Observation of all program rules, regulations and directives.

Consume no alcohol, illegal drugs or medications not prescribed by a doctor; not bring medications, special foods, or beverages into the facility without the knowledge and approval of the staff. I understand that medication prescribed will be retained and monitored by staff.

Submit to drug and/or alcohol testing in any form as required by staff.

Hold Bella Nirvana Center, its agents, members, and employees free from all liability for all personal injury or losses through fire or theft during my stay as a resident. That after leaving Bella Nirvana Center, I give, transfer, or assign all personal property left on the premises in clear title to Bella Nirvana Center if my authorized representative or I do not remove them after twenty-four (24) hours.

If, during the time that I am a resident Bella Nirvana Center and a medical emergency should occur and it is in my best interest to be hospitalized, I hereby consent to such temporary hospitalization.

I have received a copy of my personal rights and a copy of this agreement. I also understand that any violations or breach of this agreement on my part may result in the termination of this agreement.

I further agree that any violation of any of these rules or additional requirements may result in my immediate termination, discharge, and eviction from the facility, and I will vacate the premises at once.

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability.

V. MEDICAL SERVICES

For any non-emergency medical needs that arise outside the scope of the Treatment Program while I am a resident at Bella Nirvana Center, I agree to consult with Bella Nirvana Center staff to make individual, separate arrangements with the provider of the medical services. I understand that Bella Nirvana Center will neither directly pay for, nor bill for services given by an outside provider, pharmacy or other external medical supplier, and I am responsible for payment of all services outside the scope of my Treatment Program. Off-site transportation will be arranged for in consultation with Bella Nirvana Center staff and my treating provider in accordance with my Treatment Program. I authorize Bella Nirvana Center to transport me or arrange for transportation to an appropriate medical facility to receive emergency medical treatment, if necessary.

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability.

VI. FEES

Individual payment is made before being admitted or at admission to Bella Nirvana Center, unless prior arrangements have been agreed. Payment arrangements may include the use of insurance, in which case co-pays and deductibles are due at admission, or a monthly payment plan is agreed to.

All services are due and payable at admission, unless prior arrangements are agreed to by Bella Nirvana Center. Refund for services must be requested for Private payee by providing a written letter and the refund will be prorated based on the number of unattended remaining days. The sliding scale fee is based upon on clients’ needs and provided service:

Detoxification services – $1,250 per day, Residential treatment services – $1,000 per day.

The above fees also include your Incidental Medical Services. All financial arrangements must be made and agreed on prior to admission.

I agree to pay the sum of $ in exchange for days of alcohol/drug treatment services (including IMS), and the terms outlined in the ‘Financial Agreement’ beginning on . The resident agrees to authorize disclosure of proof of services for insurance or to collect a debt.

(Check appropriate Box either Insurance or Private Pay)

Residents with Insurance: Initial:

I understand that all fees incurred may not be covered by my insurance company and that I may be responsible for copays and deductible listed below:

Private Pay Residents: Initial:

$ per day for a total of Paid on Account, in Cash Check Credit Card $ Balance.

Payment Schedule:

$ due on of each month

The Resident acknowledges and agrees that any services rendered to the Resident outside the scope of services offered by Bella Nirvana Center will be at the client's expense. Such services may include, without limitation, emergency, medical care and/or dental services.

VA patients are covered through the VA insurance.

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability

VII. PROGRAM RULES

Bella Nirvana Center recognizes that a supportive environment must include clearly defined rules and regulations in order to maintain a safe and secure treatment setting. Rules and regulations include the following:

I agree to adhere to the following set of house rules for the duration of my stay as a detox resident at Bella Nirvana Center. Initial to indicate you have read and understand the house rules:

I agree to not leave the property of Bella Nirvana Center without the permission of staff as long as I am a detox resident at Bella Nirvana Center. I also understand that leaving the property without permission may result in my termination from the program.

I will not consume, in any manner, on or off the property, any alcohol or non prescribed mind-altering drugs or substances while I am a resident. Relapse on or off the property may result in discharge from the program and termination of services.

I will not be in possession of any alcohol or any mind-altering drugs or substances while l am a resident.

I agree to immediately report any prescription medications that I have to Bella Nirvana Center staff and allow them to safeguard them during my stay.

I will immediately submit to random alcohol and/or drug testing as requested by any staff member during my stay as a detox resident. To further understand that if I refuse to submit to a random test, it will result in my discharge from the program.

I will not engage in any acts of violence, threats of violence or sexual misconduct with or against other residents, staff members, or visitors during my stay. I further understand that any violation of this rule may result in my immediate discharge from the program.

I will make my bed daily, clean up after myself, be respectful of others and their property and take direction from staff.

I agree that any personal property, other than medications, that I bring into the facility and do not send home, is my responsibility; I will not hold Bella Nirvana Center responsible or liable if it is lost, damaged or stolen.

Take direction from the staff at all times.

I am aware that regular attendance is a requirement of the program; I understand that breaking this rule can result in discharge from the program.

I understand that information discussed in groups is confidential and should not be discussed outside of the program.

Behavior that undermines treatment rules and expectations will not be tolerated. Violation of these rules will result in consequences and may result in dismissal from the program. Illegal activity is subject to criminal prosecution.

RELAPSE POLICY - I understand that if I am under the influence of drugs and/or alcohol, I must comply to a Breathalyzer and/or urinalysis test when asked. Upon relapse, a reassessment of my status must be initiated to determine if there needs to be a modification to your treatment plan, including a different level of care. Should a change in level of care be required, Bella Nirvana Center shall orient you to the change, provide all pertinent information to the receiving provider, and facilitate the transition to the appropriate level of care.

If you consumed substances on premises, you will be assessed for the appropriate level of care, for any referrals needed, and a treatment plan of action will be determined. If you should relapse during the course of treatment, your care will be assessed on a case-by-case basis, addressed by the clinical treatment team, and coordinated with you based upon various factors, i.e., your progress, current treatment needs, and circumstances related to the relapse. The outcome of your relapse may include modification to your treatment plan, transition to a higher level of care, entering into a behavior contract with consequences, or may result in discharge from the program; however, Bella Nirvana Center will follow the below procedures for a relapse:

a. If you are identified as having relapsed while admitted into the program, the Director will meet with you and confer with your treatment team to determine the appropriate intervention. A reassessment of your current status will be conducted, including whether they show evidence of continued restorative potential, if they pose a safety risk to the resident’s around you by remaining in treatment, and whether you continue to meet the admission criteria for your current level of care or possibly require a higher level.

b. You will have belongings re-checked to verify if you have access to other drugs and/or alcohol.

c. You will be re-interviewed to determine where the substances came from and who provided them. If it is determined it was another resident, the resident that provided the substances will be immediately discharged.

d. You will be administratively discharged if you engage in illegal activities or compromise the safety of other residents by possessing, using, selling, or sharing alcohol or drugs on the facility grounds.

e. If you relapse and it is determined that you must be administratively discharged, you will be given referrals for alternative treatment or support resources and will be assisted in transferring to another program, should you be willing to do so.

g. As soon as the relapse is noticed, you will be placed in the detoxification protocol, with observations occurring every 30 minutes for the duration of your intoxication.

h. You will not be allowed to be off site without strict supervision.

i. You will submit to frequent testing during your remaining stay in treatment.

j. If you are determined to be more appropriate for another treatment program or a higher level of care, you will be given at least three resources/referrals.

Bella Nirvana Center rules have been explained to me so that I understand them, and I have received a copy of these rules. A resident terminated for any one or more of the above reasons may be considered for readmission at the sole discretion of the Clinical Director.

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability.

VIII. CONSENT FOR FOLLOW-UP CONTACT

The individual consent(s) to Bella Nirvana Center staff members, other healthcare professionals, or their representatives contacting the Resident or a family member by telephone in approximately one month to one year following discharge. The Bella Nirvana Center makes periodic contacts with those who have used its services, using the information to improve the services to clients, and to make sure Bell Nirvana Center is addressing clients’ needs. Specific responses are not disclosed; only summary information is assembled. This contact may also include, but not be limited to, information sent from the Bella Nirvana Center on current educational programs and newsletters.

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability.

IX. CONSENT FOR THERAPEUTIC FACILITY ACTIVITIES

Treatment for clients at Bella Nirvana Center occasionally includes activities, field trips and other therapeutic leaves away from the facility. In order for us to provide these forms of treatment, it is necessary that the Resident agree to the terms set forth in the following paragraph:

The Resident hereby acknowledges that the facility HCP may include in the treatment therapeutic trial visits away from the facility. In consideration of the value to the Resident of such treatment, the Resident hereby consent the following:

Client's participation in field trips, activities and therapeutic trial visits;

Resident releases Bella Nirvana Center, its employees and its agents from all liability for any injury to the Resident caused by any act or omission on their part in the course of such field trips, activities and leaves; and

Agree to indemnity and hold harmless the Bella Nirvana Center, its medical staff, its employees and its agents from all claims, costs and losses incurred as a result of any act of the Resident while on such field trips, activities and leaves.

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability.

X. PERSONAL BELONGINGS

I agree that upon arrival at Bella Nirvana Center, and at any point during my Treatment Program, my possessions and assigned room or area may be searched to ensure the safety of the residents and staff. I agree that Bella Nirvana Center is not liable for the loss or damage to personal items I may bring to the facility, including, but not limited to any money, jewelry, documents, eyeglasses, cell phones, laptops, other personal electronic devices, or other articles.

The following items may not be in Residents possession at any time:

Responsibility For Destruction Of Property

The Resident understands that the they are responsible for any damage to or destruction to Bella Nirvana Center property, or property belonging to others, which may be located at Bella Nirvana Center. The Resident agrees to accept liability for, and reimburse Bella Nirvana Center or other owners of property that the Resident may damage or destroy.

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability.

XI. REASONS FOR TERMINATION/EVICTION

Bella Nirvana Center implements rules and regulations that will help clients to work on their recovery. These rules and regulations are expected to be followed and abided by the clients. For some reason a Resident violated the rules, the treatment team will meet and will come up with a plan on how to deal with a situation. Following reasons that can lead to residential evictions:

Residents exhibit sexual behavior or act with the Resident or staff. Residents will be counseled with the therapist and will be put on behavioral contract, where a treatment plan will be formulated. Resident will be given a chance in the event Resident violated his/her contract that's a ground for evictions.

Resident who becomes a threat to the community.

Resident who chooses not to participate in the program to work on his/her sobriety after being counseled by the therapist or not showing improvement will be asked to leave the facility, and will be advised to go to another program that is more suited for his/her needs.

In the event Resident relapse , therapists will work on relapse prevention and helping clients to have more tools on coping skills when it comes to cravings and triggers (see relapse plan).

Termination of Agreement

Bella Nirvana Center has an open door policy. Clients will not be held against their will. If a Resident decides to leave the premises they are free to do so. The following reasons can lead to termination of agreement are:

Resident went AWOL;

Resident sneaks in and uses illicit drugs inside the residential premises;

Resident exhibits inappropriate behavior that will endanger the community and the staff;

Resident exhibits sexual behavior or act with the other client;

Resident violates behavioral contract;

Resident unable to pay daily rate; and/or

Clients’ insurance will not cover stay anymore unless Resident agrees to pay out of pocket.

This admissions agreement shall automatically terminate upon the death of the resident (no further fees, debt, or liability shall be incurred after the date of death of the resident).

Discharge Policy Information

The Resident understands that it is the policy of Bella Nirvana Center to attempt to provide a structured therapeutic regimen with effective quality treatment. If the procedure is not completed prior to the exhaustion of the client's health insurance benefits, the individual agrees to be liable for any charges incurred which are not paid by insurance benefits and the individual agrees to be liable for any charges incurred which are not paid by insurance. In addition, the Resident will be responsible for the deductible and/or co-payment liability fees. It is not Bella Nirvana Center's policy to discharge or transfer clients or end treatment regimens simply because insurance benefits have been exhausted.

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability

XII. LEVEL AND LOCATION OF SERVICES PROVIDED

Location Service Provided:

1103 Sibley St Folsom Ca 95630
813 ½ Sibley St Folsom Ca 95630
813 Sibley St Folsom Ca 95630
811 Sibley St Folsom Ca 95630
101 Honey Cook Circle Folsom Ca 95630
1141 Sibley St Folsom CA 95630

Level of Service Provided:

Detoxification
Residential
Outpatient
IOP
PHP

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability

XIII. Incidental Medical Services Certification Form Health Care Practitioner Client Assessment For Alcoholism and Drug Abuse Recovery Treatment Services

I, have reviewed the client’s initial screening questions prior to (Health Care Practitioner Name) – Please Print providing incidental medical services. I have also determined, based on the results of the questionnaire, that (Client Name) is medically appropriate to receive incidental medical services at: (Provider Name) located at: (Licensed Provider Address).

As a result of my assessment and the review of the client’s medical health questionnaire, the above client requires and will receive the following alcoholism and drug abuse recovery treatment services (list services to be provided): I also understand a copy of this form must be placed in the client’s file prior to receiving incidental medical services. I further understand that I may receive treatment services by another healthcare practitioner associated with the above licensed residential facility. Practitioner

Name (please print):

Practitioner Signature:

Date:

Client Signature:

Date:

By signing this form, I acknowledge that I have reviewed the client’s medical health questionnaire and I am approving treatment services, as listed above.

*** Health and Human Services Agency Department of Health Care Services Substance Use Disorders Compliance Division Licensing and Certification Section, MS 2600 PO Box 997413 Sacramento, CA 95899-7413

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability

XIV. CONSENT TO SELF ADMINISTER MEDICATIONS

CLIENT NAME:

I understand and agree that Bella Nirvana Center will store all my medications while I am a client here. Management of medications is part of my recovery process and I will be an active participant. I will come to the medication room when it is time for me to self administer my medications. I understand the reason for medication and what the side effects and risks are. I agree that I will notify Bella Nirvana Center staff if I begin to have an adverse reaction to this medication and/or any unusual feelings.

Bella Nirvana Center reserves the right to not return certain medication that could be harmful to the person's well-being post discharge.

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability

XV. Informed Consent for Telemedicine Services

Introduction

Bella Nirvana Center utilizes the use of electronic communications to enable health care providers at different locations to share individual client medical information for the purpose of improving client care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and /or education,and may include any of the following:

Patient medical records

Medical images

Live two- way audio and video

Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:

Improved access to medical care by providing care to patient even if the physician is at distant / other sites

More efficient medical evaluation and management

Obtaining expertise of a distant specialist.

Possible Risks:

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician.

Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;.

In very rare instances, security protocols could fail, causing a breach of privacy of personal information;

In rare cases, a lack of access to complete client records may result in adverse drug interactions or allergic reactions or other judgment errors.

By signing this form, I understand the following:

I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identities me will be disclosed to researchers or other entities without my consent.

I understand that telemedicine may involve electronic communication of my personal information.

I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but no results can be guaranteed or assured.

I have read and understand the information provided above regarding telemedicine, have discussed it with Bella Nirvana Center Staff, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my care.

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability

XVI. PSYCHOTROPIC OR PSYCHOACTIVE MEDICATION POLICY MEDICATION INFORMATION & CONSENT ATYPICAL ANTIPSYCHOTICS

Indications for Use

Antipsychotic medications are approved to treat symptoms including Depression, Anxiety, Disorganized thinking, Impaired Concentrations, Delusions, Hallucinations and Sleep disturbances.

Goals of treatment with this drug should focus on improvement of quality of life, and reduced risk of negative behavior symptoms impacting you, or those around you. Ongoing assessment of the benefits of therapy, compared to the potential risks, should be performed regularly to maximize the potential for positive outcomes.

It may take a few weeks before improvement is felt after beginning the medication. It is important to take your medication as the physician prescribes it.

Side Effects
Any medication may produce unwanted effects along with the desired results. Some side effects may appear even before any benefit from the medicine is experienced. If side effects do appear they may occasionally disappear with continued treatment.

Examples of side effects with drugs in this class may include, but are not limited to: Fall in blood pressure with body position changes, Dizziness, Constipation, Weight Gain – Increased Appetite Sleepiness or sedation, Dyspepsia, Dry mouth, Tremor or twitching, including feelings of restlessness, Agitation, Back or joint pain, Irregular heartbeat Stuttering Amnesia, Sensitivity to the sun

ALL SIDE EFFECTS SHOULD BE REPORTED & DISCUSSED WITH THE DOCTOR

Warnings and Precautions

Blood Sugar Effect- Increases in blood sugar may occur and could be complicated by pre-existing diabetes.

Cerebrovascular Adverse Events- Events such as stroke, transient ischemic attack and even including fatalities, were reported in patients in trials of atypical antipsychotics in elderly patients with dementia- related psychosis.

Tardive Dyskinesia- This is a syndrome of potentially irreversible, involuntary, dyskinetic movements. It may develop in patients treated with antipsychotic drugs.

Drowsiness and Impaired Coordination- Because of possible drowsiness and some loss of muscle control, your ability to drive, operate machinery or perform other tasks requiring alertness and coordination may be impaired. For this reason, you should avoid such hazardous duties until you are familiar with the effects this medication has upon you. Do not take this medication with alcohol. Be aware that the effects of alcohol may be intensified.

Drug Allergy- Some people may be allergic to this medication. Symptoms may be skin rash, itching, sneezing, fever or swelling of the face and tongue. If you should experience any of these symptoms, call your physician immediately.

Pregnancy and Lactation- Women should notify their physician if they become pregnant or intend to become pregnant. Women should not breast feed infants while on this medication.

Body Temperature- Because of the potential impact of atypical antipsychotics on body temperature regulation, extreme caution must be used when doing any activity that could increase body temperature, such as exercising strenuously, exposure to extreme heat, or reduced fluid intake or dehydration.

The above information has been discussed with the patient, and/or guardian/conservator, if appropriate, who reports them to be understood and agrees to take the medication.

I acknowledge that I am responsible for following my physician’s recommendations and to do what is necessary to control and treat my condition.

I understand that the sole responsibility of my health and well being is in my hands in view of the above and that I cannot reasonably hold my physician responsible if I do not adhere to his recommendations and /or not take medications as I am instructed to do so.

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability

XVII. Authorization to Release and Obtain Information for Admission

I, , DOB: , SSN:
Authorize Bella Nirvana Center (BNC), to release or obtain information contained in my treatment record.

Emergency & Contact Name:
Relationship to client :

Address:
Phone :

Information to be released: ( Required ) only specific information will be released. Clients must check information to be released.

Verify Admission/Discharge	Aftercare plan	Treatment Plan review
Discharge Summary	Medications	Psychiatric consult/evaluation notes
History and Physical	Labs /UDS	Progress in treatment

Insurance Company: Phone:

Verify Admission/Discharge	Aftercare plan	Treatment Plan review
Discharge Summary	Medications	Psychiatric consult/evaluation notes
History and Physical	Labs /UDS	Progress in treatment

Primary Care Physician: Phone:

Verify Admission/Discharge	Aftercare plan	Treatment Plan review
Discharge Summary	Medications	Psychiatric consult/evaluation notes
History and Physical	Labs /UDS	Progress in treatment

Client Signature:

Date:

Staff Signature:

Date:

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability.

XVIII. Meal Plan Notification Form

Date:

Meal Plans: Regular
Vegetarian
Other

Dietary Issues:
Gastric Bypass

Diabetes

Celiac Disease

Kidney Disease

Pregnancy

Liver Disease

Chewing/Swallowing/Tooth/Gum Problems

Other

****If checking of the above dietary issues please advise Client about dietary recommendations****

Food ALLERGIES:

Staff Signature:

Please place the completed dietary form to the dietary mail box for the chef to check.

Staff Notes:

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability.

XIX. Consent For Follow Up Contact

The individual consent(s) to Bella Nirvana Center staff members, other healthcare professionals, or their representatives contacting the client or a family member by telephone in approximately one month to one year following discharge. The Bella Nirvana Center makes periodic contacts with those who have used its services, using the information to improve the services to clients, and to make sure Bella Nirvana Center is addressing clients needs.

Specific responses are not disclosed; only summary information is assembled. This contact may also include, but not be limited to, information sent from the Bella Nirvana Center on current educational programs and newsletters.

Client Signature:

Date:

Staff Signature:

Date:

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability.

XX. RESIDENT RIGHTS

Clients have the right to personal dignity and to be accorded dignity in personal relationships with staff and other persons.

Clients have the right to impartial reasonable access to care and treatment and/or accommodations that are available or medically advisable regardless of one's race, color, creed, religion, sex, sexual orientation, gender identity, national origin, disability, age, status as a disabled veteran, having an Advance Directive or ability to pay for care.

Clients have the right to be accorded safe, healthful and comfortable accommodations to meet his or her needs.

Clients have the right to care that is considerate and respectful of their cultural and personal values, and beliefs, as well as their psychosocial values and preferences.

Clients have the right to express their values and beliefs and to exercise spiritual and cultural beliefs that do not interfere with the delivery of client care and the well-being of others.

Clients have the right to have access to spiritual care counseling and to be free to attend religious services or activities of his or her choice and to have visits from a spiritual advisor provided that these services or activities do not conflict with facility program requirements. Participation in religious services will be voluntary only.

Clients have the right to have reasonable access to an interpreter when they do not speak or understand the English language.

Clients have the right to a reasonably safe and secure environment.

Clients have the right to be free from all forms of abuse or harassment, including emotional, intellectual, and/or physical abuse.

Clients, their families, including a registered domestic partner and/or their legally authorized surrogate decision-maker(s) have the right, in collaboration with their physician, to be informed and make decisions involving their health care, including the right to accept medical care or to refuse treatment to the extent of the law and to be informed of the medical consequences of such refusal.

Clients have the right to be informed of outcomes of care, treatment and services, including unanticipated outcomes.

Clients have the right to access their own health information, request amendment to it, and receive an accounting of disclosures about it, as permitted under applicable law.

Clients have the right to have a family member, including a registered domestic partner, surrogate decision-maker, and their own physician (if requested) notified.

Residents have the right to formulate advance directives regarding end-of-life decisions and mental health treatment to appoint a surrogate to make healthcare decisions on his/her behalf to the extent of the law.

Clients have the right to be fully informed of their health care needs and the alternatives for care when a hospital cannot provide the care that a client requests. If it is necessary and medically advisable, the Resident may be transferred to an appropriate and acceptable facility.

Clients have the right to consideration for their personal privacy and confidentiality of information.

Clients have the right to confidentiality as provided for in Title 42, Subchapter A, Part 2 Sections 2.1 through 2.67-1, Code of Federal Regulations.

Clients have the right to participate in discussion of ethical questions that arise in the course of their care. Clients or family members may request an ethics consultation regarding issues of conflict resolution, withholding resuscitative services, foregoing or withdrawal of life-sustaining treatment, and participation in investigational studies or clinical trials, and other ethical concerns.

Clients have the right to obtain a written statement that articulates the rights and responsibilities of clients. The statement is available in several languages specific to the populations served. If the client cannot read or if the statement is not available in their language, interpretive assistance will be available.

Clients have the right to access protective services. Children or vulnerable adults who are unable to care for themselves have the right to protective intervention by the appropriate agencies to correct hazardous living conditions, abuse, neglect or exploitation.

Clients have the right to make complaints regarding their care accordingly. Clients voicing complaints will not be subject to coercion, discrimination, reprisal or unreasonable interruption of care. Clients also have the right to be informed by the licensee of the provisions of law regarding complaints including but not limited to the address and telephone number of the department.

Clients have the right to request and receive an itemized and detailed explanation of their bill for services rendered.

I acknowledge I have received a copy of these rights.

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability.

XXI. ACKNOWLEDGEMENTS

I agree to the above terms and I understand that by signing this agreement I understand that verification of benefits as quoted by the insurance company is not a guarantee of payment. A determination of eligibility of an individual and/or the amount of a benefit to be paid can only be made after a claim is submitted and reviewed. I agree that if the claim is denied I will take full responsibility for the bill for treatment services. If I fail to take responsibility for the bill or fail to abide by the payment schedule agreed upon above, the account will be in arrears and will be turned over to a collection agency. I may also be subject to finance charges, legal fees, and any other fee(s) incurred attempting to collect a debt.

I understand that my records are protected under Federal Confidentiality regulations (42 U.S.C. 290dd-3 and 42 U.S.C. 290ee·3 for Federal law; and 42 CFR Part 2 for Federal regulations) published August 10, 1987 and cannot be disclosed without my written consent unless otherwise provided in the regulations. I understand that my record may contain information concerning my psychiatric, psychological, drug or alcohol abuse, HIV/Acquired Immune Deficiency Syndrome (AIDS), and/or related conditions.

This contract sets forth the entire agreement between the parties and replaces all other oral Bella Nirvana Center or written provisions made by any representative of the program. This contract may be modified or terminated only in another written document signed by all parties. If this admission agreement is modified, the resident will receive a fully executed copy of the modified agreement.

My signature below as ‘Resident’ or ‘Authorized Representative’ indicates that I have read, or had read and explained to me, the provisions of this agreement and that I enter into this agreement voluntarily.

The undersigned applies for admission as a resident at Bella Nirvana Center. By accepting residents at the facility, Bella Nirvana Center does not warrant or agree to affect a cure. The above conditions and provisions govern the treatment, care and accommodations provided to all residents at Bella Nirvana Center. I confirm that I have read the foregoing and received a copy thereof. I am the resident, the resident’s legal representative, or am otherwise authorized by the resident to sign this Admissions Form and accept its terms on his/ her behalf.

I, validate, with my signature below, that I have received a copy of this agreement

Resident Signature:

Date:

Guarantor Printed Name (if applicable):

Guarantor Signature (if applicable):

Date:

Staff Printed Name

Staff Signature (if applicable):

Date:

Consent*

I Agree to the terms and conditions. The above information provided is accurate to the best of my ability.