VITA NOVA INTAKE FORM

Consent To Treat Contract
I, the undersigned, do hereby acknowledge that:*
First Last
1. I have voluntarily consented to become a client of True North Recovery Inc and that this voluntary consent is true, regardless of the fact that I may be court ordered to the program.
2. I understand that all things spoken about in group are confidential and should not be shared with anyone outside of treatment. I will respect all participants confidentiality.
3. I am aware that True North Recovery Inc is a chemical dependency/mental health treatment program. The general outline, purpose, and methods of treatment offered by True North Recovery Inc has been approved by the Alaska Department of Behavioral Health and is evidenced based curriculum and practices. “ I agree to participate
4. I further understand that part of my treatment at True North Recovery Inc may require me to submit urine samples for analysis of drug content. Further requirements may include psychological, psychiatric, or general health testing, disclosure, and monitoring of prescribed medications. I consent to undergo these procedures.
5. I acknowledge and understand that no promise or guarantees have been made to me regardless of the outcome of my treatment by True North Recovery Inc and do hereby absolve True North Recovery Inc from liability in the event my treatment is unsuccessful.
6. I hereby agree to comply with and abide by the policies, rules, and regulations of True North Recovery Inc in my treatment.
Check Box To Agree To Terms (Required to Proceed)*
I have read each paragraph contained above and have had the opportunity to clarify questions I have regarding these. Accordingly, I acknowledge that I duly understand the provisions of the document and its legal consequences.
FEES FOR SERVICE:
1. I agree to pay the cost of my treatment. I will make arrangements with the Financial Office before starting my treatment program.
2. I acknowledge that all fees for services are due and payable at the time of service unless other arrangements have been made.

ATTENDENCE:
1. I agree to be on time for all scheduled groups and counseling sessions. I understand that if I am late I may not be admitted to the group session.
2. Subject to ongoing assessment and evaluation of my treatment progress, I may expect changes in the level and duration of services while I am enrolled. Further, I may expect these changes to be discussed by the treatment team and any modifications will be in the best interest of my treatment.
3. My attendance at other support groups such as Alcoholics Anonymous, Narcotics Anonymous, Adult Children of Alcoholics, etc. may be required of me as determined by the treatment team.

ABSTINENCE:
1. Abstinence from non-prescribed, mind/mood altering chemicals (including alcohol) is clearly the primary goal of this program, unless contraindicated by my assessed special needs. Therefore, I agree to maintain abstinence from these chemicals while in treatment. My failure to comply with this abstinence policy will result in an immediate re-evaluation of my treatment needs and may result in termination from this program.
Check Box To Consent To Terms (Required to Proceed)*
I have read and agree to comply with the above contract for treatment.
Client Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Client Signature*
Date
MM slash DD slash YYYY
Counsellor Signature
Date
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Financial Responsibility Agreement
If you come in to sign up for a treatment program you must provide proof of your household gross income at your financial appointment. Your financial contract must be completed before you begin treatment.
Ultimately you, the client, are responsible for payment of all services.
• If you have INSURANCE please bring your insurance ID card, or insurance form with patient portion completed and signed. We will gladly bill your insurance. If your insurance does not cover any portion of your costs you will then become eligible for the sliding fee scale. You may want to call your insurance company or look in your policy to determine if your insurance covers the treatment you are about to begin.
• If you are covered by MEDICAID OR DENALI KID CARE please bring in your sticker, coupon, or card covering the current month. If Medicaid does not cover any portion of your costs you will then become eligible for the sliding fee scale. You will then become responsible for payment.
If you DO NOT have Insurance, Medicaid, or Denali Kid Care you must bring your most recent TAX RETURN, W-2, and 1099 (if applicable) And any of the following that apply:
• LAST TWO CHECK STUBS (IF MARRIED SPOUSES ALSO)
• UNEMPLOYMENT
• WORKMANS COMPENSATION
• SOCIAL SECURITY INCOME
• RETIREMENT PENSION
• DISABILITY INCOME
• PUBLIC ASSISTANCE
• NATIVE CORPORATION DIVIDENDS

If you do not provide adequate proof of income you will be charged at our customary full rate.
Client Name*
First Last
Client Signature*
Date
MM slash DD slash YYYY
Guardian Signature (Live signature required)
Date
MM slash DD slash YYYY

Client Medical Release / Emergency Information Form
For Your Safety, the following information will be kept in a secure area, accessible only to staff members, while you are attending group.
All information must be current in case of emergency. Please complete the following:
I the undersigned hereby,*
First Last
Give my consent to be given emergency medical treatment in the event of an accident, injury or illness.
I hereby release the True North Recovery Inc and its representatives from any liability rising from an emergency situation in which it is deemed necessary to pursue medical treatment.
In case of an emergency, True North Recovery Inc may contact:
Name / Relationship*
Phone*
Name / Relationship*
Phone*
Drug Allergies:*
Medication:*
List Any Other Medical Conditions: (If none use N/A)*
Client Signature*
Date*
MM slash DD slash YYYY
Guardian Signature (Live signature required)
Date
MM slash DD slash YYYY

Consent For The Release Of Confidential Information Substance Abuse Program, Medicaid, First Health Service Corporation, and State Of Alaska DHSS Division Behavioral Health
Instructions: Please fill in the blanks/check the boxes for each question. Do not leave anything blank.
I, undersigned, authorize the following agencies to communicate with and disclose to one another via verbally, electronically, or in writing the following initialed information.*
First Last
True North Recovery Inc.
591 S. Knik Goose Bay Rd
Wasilla, AK 99654
State Of Alaska DHSS
Division Of Behavioral Health
PO Box 110607
Juneau, AK 99811-0607
Conduent
PO Box 240808
Anchorage, AK 99524-0808
Medicaid
NOTE: By signing below you are agreeing to the following items to be released:
✓ My name and other personal identifying information
✓ Initial evaluation
✓ Assessment results and history
✓ Attendance
✓ Date of discharge and discharge status
✓ My status as a patient in alcohol and/or drug treatment;
✓ Date of admission
✓ Summary of treatment plan, progress, and compliance
✓ Urinalysis results
✓ Discharge plan
The purpose of the disclosures authorized in this consent is to enable the agencies listed above to evaluate my claims for insurance coverage and reimbursement.
I understand that my alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Patient Records, 42 C.F.R. Part 2 and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Pts. 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent in writing at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows:
The date on which my insurance claims for this course of alcohol or drug abuse treatment have been completely processed.
I understand that generally True North Recovery Inc. may not condition my treatment on whether I sign this consent form, but that in certain limited circumstances I may be denied treatment if I do not sign a consent form.
Patient Signature*
Date*
MM slash DD slash YYYY
Parent or Guardian Signature (Live signature required)
Date
MM slash DD slash YYYY
Program Representative Signature
Date
MM slash DD slash YYYY

Client Notice
This notice describes how medical and drug and alcohol related information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
General Information: Information regarding your health care, including payment for health care, is protected by two federal laws: The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 42 U.S.C. 1320d et seq., 45 C.F.R. Parts 160 & 164, and the Confidentiality Law, 42 U.S.C. 290dd-2, 42 C.F.R. Part 2. Under these laws, True North Recovery Inc. (TNR) may not say to a person outside TNR that you attend the program, nor may TNR disclose any information identifying you as an alcohol or drug abuser or disclose any other protected information except as permitted by federal law.
True North Recovery Inc. must obtain your written consent before it can disclose information about you for payment purposes. For example, TNR must obtain your written consent before it can disclose information to your health insurer in order to be paid for services. Generally, you must also sign a written consent before TNR can share information for treatment purposes or for health care operations. However, federal law permits TNR to disclose information without your written permission:
1. Pursuant to an agreement with a qualified service organization/ business associate;
2. For research, audit or evaluations;
3. To report a crime committed on TNR’ premises or against TNR personnel;
4. To medical personnel in a medical emergency;
5. As allowed by an authorizing court order.
6. Physical or sexual abuse or neglect committed against a child or elderly person
7. Suicidal or homicidal threats or attempts
8. Internal Communications

For example, TNR can disclose information without your consent to obtain legal or financial services, or to another medical facility to provide health care to you, as long as there is a qualified service organization/business associate agreement in place.
Before TNR can use or disclose any information about your health in a manner which is not described above, it must first obtain your specific written consent allowing it to make the disclosure. Any such written consent may be revoked by you in writing.
YOUR RIGHTS Under HIPAA you have the right to request restrictions on certain uses and disclosures of your health information. TNR is not required to agree to any restrictions you request, but if it does agree then it is bound by that agreement and may not use or disclose any information which you have restricted except as necessary in a medical emergency.
You have the right to request that we communicate with you by alternative means or at an alternative location. TNR will accommodate such requests that are reasonable and will not request an explanation from you. Under HIPAA you also have the right to inspect and copy your own health information maintained by TNR, except to the extent that the information contains psychotherapy notes or information compiled for use in a civil, criminal or administrative proceeding or in other limited circumstances.
Under HIPAA you also have the right, with some exceptions, to amend health care information maintained in TNR’ records, and to request and receive an accounting of disclosures of your health-related information made by TNR during the seven years prior to your request. You also have the right to receive a paper copy of this notice. TNR may deny a client request for amendment if it determines that the information or record:
• Was not created by an TNR employee
• Is not part of a designated record set
• Is accurate and complete

A client, whose request for amendment is denied, may pursue the next appropriate level of the client grievance procedure.
TNR’ Duties TNR is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. TNR is required by law to abide by the terms of this notice. TNR reserves the right to change the terms of this notice and to make new notice provisions effective for all protected health information it maintains. Any revisions to this policy will be distributed to you at your next scheduled session or appointment.
Complaints and Reporting Violations You may complain to TNR and the Secretary of the United States Department of Health and Human Services if you believe that your privacy rights have been violated under HIPAA. You may file a complaint if you believe your privacy rights have been violated by completing a complaint form (available at the front desk) and following the steps of the Grievance Procedures. You will not be subject to retaliation for filing such a complaint.
A violation of the Confidentiality Law by a program is a crime. Suspected violations of the Confidentiality Law may be reported to the United States Attorney in the district where the violation occurs.
Contact For further information, contact TNR by telephoning 907-313-1333 Effective Date 7/2018
Check Box To Acknowledge (Required To Proceed)*
I hereby acknowledge that I received a copy of this notice.
Patient Signature*
Date*
MM slash DD slash YYYY
Guardian Signature (Live signature required)
Date
MM slash DD slash YYYY

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