Wilderness Treatment Center 200 Hubbart Dam Rd. Marion, MT (406) (406) fax
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- Bartholomew Homer Garrison
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1 Wilderness Treatment Center 200 Hubbart Dam Rd. Marion, MT (406) (406) fax ADMISSION Wilderness Treatment Center is an inpatient free-standing facility for males years old. The program is approximately 60 days with the actual length of stay based on how the patient progresses through the treatment process. Patients may be admitted either by self, by their physicians, family, clergy, or other treatment programs and professionals. Admissions are scheduled seven days a week. Contact the admissions coordinator at the business office Monday through Friday for 8:00 a.m. to 5:00 p.m. M.S.T. to make necessary arrangements. COST $425 Per Day Wilderness Treatment Center includes room, board, and all therapy. $500 Clothing Allowance (upon admission) Clothing for Wilderness Expedition, fishing license, film, etc. All equipment such as backpacks, sleeping bags, etc. is provided. Any equipment damage due to abuse will be billed to patient s account. $0 Family Week Our 4 ½ day family program is held once per month, utilizing the principles of the Al-Anon program and family system dynamics. Our family therapists are available Sunday through Thursday for phone conferences and will arrange a family week attendance with you. $0 Aftercare Aftercare is the responsibility of the patient and family. The patient and his counselor will make arrangements for aftercare during the last phase of treatment. ACCREDITATION Wilderness Treatment Center is a licensed, free-standing, in-patient treatment center that uses the steps of A.A. and N.A. The program is medically supervised and covered by some medical insurance plans. Wilderness Treatment Center is licensed through the State of Montana Department of Public Health and Human Services, Addiction and Mental Health Disorders Division.
2 Wilderness Treatment Center 200 Hubbart Dam Rd. Marion, MT (406) (406) fax (Patient Name) PLEASE READ CAREFULLY ACKNOWLEDGEMENT OF RISK ASSUMPTION OF RISK AND RESPONSIBILITY All participants will be actively involved in a wilderness expedition during week five, six, and seven. There are significant elements of risk in any adventure that travels beyond the trailhead in which trekking, hiking, mountaineering, rappelling, rock climbing, skiing, solo, snowshoes, backpacking, fishing or initiative games can occur. ACKNOWLEDGEMENT OF RISK: In agreeing to have your son attend WTC, you recognize the fact that there is an inherent danger in the following activities: 1) Falls, 2) Cold weather related injuries including hypothermia and frostbite, 3) Heat-related illness including heat exhaustion and heat stroke, 4) Acts of nature which may include: avalanche, rock falls, crevice falls, high winds and severe cold, 5) River crossings, fording or travel, including travel to and from the activities, 6) Risks associated with crossing, climbing or down climbing rocks and ice, 7) Equipment failure. I/we also acknowledge that certain foreseeable or unforeseeable events may contribute to the unpredictability of the activity. Personal property may be damaged or lost and that I/we may suffer an accident or illness in remote places where there is no available medical facility and that wearing a helmet and appropriate clothing are basic safety precautions. As a potential user of the services Wilderness Treatment Center provides you have a right to ask the safety record and accident incidents of past participants at Wilderness Treatment Center. PARENT SIGNATURE PATIENT SIGNATURE
3 Wilderness Treatment Center 200 Hubbart Dam Rd. Marion, MT (406) (406) fax CONSENT TO MEDICAL CARE AND TREATMENT I, (legal guardian), authorize all medical and surgical treatment, x-ray, laboratory, anesthesia, and other medical/hospital procedures as may be performed or prescribed by a licensed physician for, (patient s name) and waive my right to informed consent of treatment. Birth Date Birthplace Mother s Maiden Name Allergies Chronic Illnesses Regular Medications Date of Last Tetanus Immunization Patient s Physician Physician s Phone Number Mother s Emergency Contact Number Father s Emergency Contact Number Date Signature of Legal Guardian Witness Patient s Address
4 HEALTH INSURANCE AUTHORIZATION FORM WILDERNESS TREATMENT CENTER (Patient) In cases where the patient is covered for the cost of care and treatment, under an insurance plan, either his own or under that of the responsible person: it is necessary to obtain the signature of the policy-holder on the following authorizations before a claim may be submitted for payment. AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize the above treatment center to release medical information necessary to process this claim following the HIPPA Act. Date: Signature: AUTHORIZATION TO PAY INSURANCE BENEFITS: I hereby authorize payment of the Hospital Benefits herein specified and otherwise payable to me, directly to the Treatment Center. I also understand that I am financially responsible for all charges not covered by the insurance company. Date: Signature: Please answer the following questions to the best of your ability. Insurance Company s Name and Address: Insured s Name and Address: Insured s Identifying Number/Social Security Number: Insured s Group Number: Policy Number: Insured s Certificate Number or Other: If patient has other health insurance, health plan or state assistance, enter its name, address, and policy or medical assistance number here:
5 WILDERNESS TREATMENT CENTER PROGRAM COSTS ***** PLEASE READ AND FAX BACK ***** The following is an explanation of the billing procedures for WTC. The cost of treatment is $425/day and the average length of stay is 60 days, however, there are many factors that are involved in the length of stay. The progress of the patient, admission date, the family week schedule, and the wilderness trip so approximately 67 days is a possibility. The $425/day includes: Room and Board Individual and Group Therapy Education groups, lectures and videos Parent consultation and weekly updates Complete physical exam and lab work Psychological test Family week Recommendations with the aftercare placement The $500 clothing allowance is kept in a separate account and this is for the wilderness expedition for gear and clothing. The extra charges that may be on the bill are any extra doctor visits for sickness, medication reviews, or insurance phone conferences with the Medical Director and the insurance company. Any medications, extra blood tests, x-rays, damages or incidental expenses will be on the final bill. If there is insurance we need to know prior to admission as it will affect any coverage if we send it in late due to preauthorization. The insurance company is not billed until the patient is discharged from treatment and it then takes a minimum of 30 days to hear anything. The down payment and 30 days payment must be paid timely on the due dates and there are no variations in payments unless arranged prior to admission. We have a 72 hour hold policy which means there is no fee adjustment or reductions for periods in which a patient is not physically at WTC, if they leave the facility unauthorized we hold the bed and bill accordingly. Please read this and sign and return with the fee payment agreement that you understand the billing procedure and agree with the treatment process, length of stay and agree to pay accordingly. Date: Parent Name: Patient Name:
6 Wilderness Treatment Center 200 Hubbart Dam Rd. Marion, MT (406) (406) fax FEE PAYMENT AGREEMENT ***** PLEASE SIGN AND FAX BACK ***** Date: Patient Name: I understand that the cost of treatment is $425 per day for Wilderness Treatment Center s 60 day program. If the patient stays for 60 days, the cost is $26,000. If the patient stays longer than 60 days, the charge is still $425 for each additional day. I also understand that there is a $500 clothing allowance for the wilderness trip, which is due upon admission. We accept Visa, MasterCard, Discover and American Express and will include a non-refundable 3% administrative fee on each transaction if a card is used for payment. The amount of the down payment is $14,000 and is due on admission. The 30 day payment will be $12,000 and is due on 30 days after admission. Any additional balance for days beyond the 60 day stay is due and payable upon discharge from our program. A final bill will be sent upon discharge for any additional charges. Past due accounts shall bear interest at the rate of 18%. All accounts not paid within 60 days of discharge shall be subject to collection in accordance with our collection policy and that in the event of collection, I agree to pay any and all costs of collection, including litigation costs and reasonable attorney fees incurred. Wilderness Treatment Center will try and work with your insurance carrier, however, please note that there is no guarantee of payment from the carrier. An insurance claim will be submitted after discharge for WTC. If payment from the insurance carrier comes directly to WTC, a refund for any overpayment will be processed in a timely manner. Signature Signature SS# SS# Address and Phone
7 Patient# SSN: Wilderness Treatment Center Date: Patient Name: Age: DOB: How did you hear about us: Parent Phone Address Insurance Policy # Group # Phone Employment SSN: Parent Phone Address Drug of Choice Secondary Duration and Frequency of Use Prior Treatment: Yes No Inpatient Outpatient Previous Programs and Dates: 1) 2) 3) 4) 5) 6)
8 Current Living Situation: Siblings (Name and Ages) Physical Condition Allergies Medications Family Physician Phone Immunization Record Person s perception of own alcohol/drug problem: Accepts Denies Comments Age person started using chemicals Consequences of use Legal Status: N/A Probation Parole Court Ordered Probation Officer Phone Attorney Phone Mental Status (any mental health concerns/history of trauma/etc ) Needs or Focus Ares Additional Information
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