MAIL: Recovery Center Missoula FAX: Wyoming St. OR ATTN: Admissions Missoula, MT ATTN: Admissions

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1 Hello and thank you for your interest in Recovery Center Missoula. This letter serves to introduce our program to you, outline eligibility requirements, and describe the application/admission process. Whether you are referring someone to the Center, or are seeking help for yourself or a loved one, we hope you will find the application and admission process to be easy. If you have any questions, please contact Recovery Center Missoula (RCM) at any time; There will always be someone to answer your call. RCM is designed to meet the needs of those suffering from substance use disorders/ addiction and cooccurring emotional or psychiatric disorders. The Center utilizes evidence based therapeutic interventions to promote a healing recovery process that can last a life time. Recovery Center Missoula offers inpatient treatment and partial hospitalization/day treatment services to adults 18 and over. If medically indicated, detox services are also available at RCM and can be scheduled according to your specific need. There are three main application eligibility requirements for admission to RCM: 1. Applicant must meet clinical criteria for inpatient or partial hospitalization services. 2. Applicant must have a current chemical dependency assessment with a diagnosis of dependence or addiction, completed by a Licensed Addiction Counselor (LAC). This can be accomplished at Recovery Center Missoula or with a LAC of the applicant s choice. In most situations RCM can have direct communication with the applicant s physician or evaluating counselor to facilitate a timely admission. If assistance is needed in finding an LAC, call RCM and we will provide referral options. 3. Applicant must be at least 18 years of age. The process for submitting an application to Recovery Center Missoula follows: 1. Print out and complete and return this initial application packet by: MAIL: Recovery Center Missoula FAX: Wyoming St. OR ATTN: Admissions Missoula, MT ATTN: Admissions 2. Once the completed application packet has been received, the applicant will be contacted by the Admissions Coordinator about any additional documentation that may be necessary to preauthorize insurance coverage. RCM staff can assist in exploring other resources and options for payment if insurance is not available. 3. An admission date for inpatient services or partial hospitalization will be established once all necessary documentation is complete and financial arrangements are in place. If you have questions during any part of this process, please do not hesitate to call Recovery Center Missoula, or e mail rcm@wmmhc.org. We sincerely hope our program may be of service to you. Respectfully, Recovery Center Admissions Staff

2 APPLICATION FOR SERVICES Name: Date: Last First Maiden/Middle Physical Address: Street Address City, State Zip Mailing Address: Street Address City, State Zip Home #: Work #: Cell# Birth Date: Age: Social Security #: County of Residence: Gender (circle One) Male Female Marital Status (circle one) Married Unmarried Divorced Committed/cohabiting Race/Ethnicity (Circle One): 1. White 3. American Indian 5. Asian/Pacific Islander 7. Hispanic Puerto Rican 2. Black 4. Alaskan Native 6. Hispanic Mexican 8. Hispanic Cuban 9. Hispanic Who Referred You: Phone: Your Occupation: Employment Status (Circle One): 1. Employed Full Time 2. Employed Part Time 3. Unemployed 4. Not in the Labor Force Place of Employment: Annual Family Income from ALL sources: $ Household Size: (Last Taxable Year) Years of Education Completed: Highest degree obtained: CHECK HERE IF YOU ARE A WOMAN WITH DEPENDENT CHILDREN UNDER THE AGE OF 18 Children s ages and gender: Health Insurance (Circle One): Blue Cross/Blue Shield Other Insurance: Medicare Medicaid NONE Name of Insured: Relationship (circle one): Self Spouse Parent Other Insurance Group # ID #

3 Number of Days in Treatment Prior 12 Months: Inpatient Outpatient Date of last TX Longest period of abstinence following any treatment episode: Have you ever used drugs by injection (Circle One): 1. Never 3. Not in the Last 12 months, but SINCE During the Last 12 Months? Current? 4. Not since 1978, but BEFORE 1978 Primary Care Physician: Phone Other physician/specialist: Phone Pharmacy (s): Current Medications and Dosages: Current Therapist: Phone: Emergency Contact: Relationship: Phone: Previous or Current Diagnosis: Chemical Dependency Mental Health Physical Health (circle one): EXCELLENT GOOD FAIR POOR Current Medical Issues:

4 Any special medical needs: Are you pregnant or do you suspect you are Pregnant? Yes No How Many Weeks?: Current Legal Involvement: Please Circle the answer that is correct for you: Screening for alcohol withdrawal potential How often do you have a How many drinks containing alcohol How often do you have six or more drink containing alcohol? do you have on a typical drinks on one occasion? day when drinking? Never 1 or 2 Never Monthly or less 3 or 4 Less than monthly 2 4 times a month 5 or 6 Monthly 2 3 times a week 7 to 9 Weekly 4 or more times a week 10 or more Daily or almost daily STAFF USE ONLY AUDIT C Score

5 Recovery Center Missoula PRIVACY 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, 45 U.S.C. 290dd 2, 42 C.F.R. Part 2. Under these laws, Recovery Center Missoula, Inc. (RECOVERY CENTER MISSOULA) may not say to a person outside RECOVERY CENTER MISSOULA that you attend the program, nor may RECOVERY CENTER MISSOULA disclose any information identifying you as an alcohol or drug abuser, or disclose any other protected information except as permitted by federal law. RECOVERY CENTER MISSOULA must obtain your written consent before it can disclose information about you for payment purposes. For example, RECOVERY CENTER MISSOULA 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 RECOVERY CENTER MISSOULA can share information for treatment purposes or for health care operations. However, federal law permits RECOVERY CENTER MISSOULA 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 RECOVERY CENTER MISSOULA premises or against RECOVERY CENTER MISSOULA personnel; 4. To medical personnel in a medical emergency; 5. To appropriate authorities to report suspected child abuse or neglect; 6. As allowed by a court order. For example, RECOVERY CENTER MISSOULA 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 RECOVERY CENTER MISSOULA can use or disclose any information about your health in a manner that 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. RECOVERY CENTER MISSOULA 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. RECOVERY CENTER MISSOULA 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 RECOVERY CENTER MISSOULA, except to the extent that the information contains psychotherapy notes or information compiled for use in civil, criminal or administrative proceedings or in other limited circumstances. Under HIPAA you also have the right, with some exceptions, to amend health care information maintained in RECOVERY CENTER MISSOULA s records, and to request and receive an accounting of disclosures of your health related information made by RECOVERY CENTER MISSOULA during the six years prior to your request. You also have the right to receive a paper copy of this notice. RECOVERY CENTER MISSOULA Duties RECOVERY CENTER MISSOULA 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. RECOVERY CENTER MISSOULA is required by law to abide by the terms of this notice. We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at the Reception Desk at RECOVERY CENTER MISSOULA. The notice will contain on the first page, in the top right hand corner, the effective date. In addition, each time you are admitted to RECOVERY CENTER MISSOULA for treatment or health care services, we will offer you a copy of the current notice in effect. Complaints and Reporting Violations If you believe your privacy rights have been violated, you may file a complaint with RECOVERY CENTER MISSOULA or with the Secretary of the Department of Health and Human Services. To file a complaint with RECOVERY CENTER MISSOULA, contact our Privacy Officer, RECOVERY CENTER MISSOULA, 1201 Wyoming St., Missoula, MT or by telephone at ext All complaints must be submitted in writing. You will not be penalized for filing a complaint. Violations of the federal laws and regulations by RECOVERY CENTER MISSOULA are a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations. Contact For further information, contact: Privacy Officer, Recovery Center Missoula., 1201 Wyoming St., Missoula, MT 59801, (406) THANK YOU!!