As a participant in medication treatment for opioid misuse and dependence, I freely and voluntarily agree to accept this treatment contract as follows. I understand that addiction is a bio-psycho-social disease and that all three components of the disease must be treated in order to stabilize the disease process. The biological part of the disease is psychiatric care. The psychological aspect is treated within individual and group counseling. The social aspect is treated with 12 Step support and/or other support groups for substance use problems.

 

 

• I understand that this consent expires in one year, or when revoked by me, as evident by my signature below.
• There has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or another proceeding under which I was mandated into treatment.
• I understand, as evident by my signature below, that the records requested may be protected under 42 C.F.R. Part 2 governing Alcohol & Drug Abuse Patient Records & State Confidentiality Laws & Regulations and cannot be released without my consent unless otherwise provided for by regulation. State & Federal Law regulations prohibit any further disclosure of such records without my specific written consent or except when otherwise permitted by such regulation.
• I understand, as evident by my signature below, that treatment services at this agency are not contingent upon or influenced by my decision to permit the release of any information. I also understand that I may revoke this consent in writing at any time unless action has already been taken based upon it and that in any event, this consent expires in one (1) year from the date of signing or upon conditions described above.
• THE INFORMATION I AUTHORIZE FOR RELEASE MAY INCLUDE RECORDS WHICH MAY INDICATE THE PRESENCE OF A COMMUNICABLE OR VENEREAL DISEASE WHICH MAY INCLUDE, BUT ARE NOT LIMITED TO DISEASES SUCH AS HEPATITIS, SYPHILIS, GONORRHEA, AND THE HUMAN IMMUNE DEFICIENCY VIRUS ALSO KNOWN AS ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS). RECORDS MAY ALSO INCLUDE PSYCHIATRIC INFORMATION AND ALCOHOL AND DRUG ABUSE INFORMATION.
• NOTICE TO RECIPIENTS OF ALCOHOL AND DRUG ABUSE TREATMENT RECORDS!! The information received in accordance with this release may be used only for the purpose as set forth above. This notice accompanies a disclosure of information concerning a client in alcohol/drug treatment, made to you with the consent of the client.
• This information has been disclosed to you from records protected by Federal Confidentiality Rules (42 C.F.R. Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R Part 2, and the health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R Pts. 160 & 164. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse treatment patient.

Confidentiality of Substance Use Disorder Patient Records

The confidentiality of alcohol and drug abuse patient records maintained by this program is protected by federal law and regulations. Generally, the program may not say to a person outside of the program that a patient attends the program or disclose any information identifying a patient as an alcohol or drug abuser unless:

1. The patient consents in writing or
2. The disclosure is allowed by a court order
3. The disclosure is made to medical personnel in a medical emergency or to a qualified person for research, audit, or program evaluation
4. The patient commits or threatens to commit a crime at the program or against any person who works for the program

Federal law and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.

• I understand that my alcohol and/or treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse 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 recipients of this information may re-disclose it only in connection with their official duties.

CONSENT FOR CAMERA SURVEILLANCE

• It has been explained to me and I have been made aware that detoxification rooms are under continuous camera surveillance strictly for observation purposes and I consent to such.
• It has also been explained to me and I have been made aware that Freedom House uses video surveillance that includes audio recording, video recording outside dorms, and around the grounds for the protection of my safety. Staff may also use confidential electronic transmission of client data for efficient service delivery.
• I have also been made aware that a photo will be taken of me to place in my permanent file upon admission into a treatment

Information about your healthcare, including payment, is protected by State and Federal Law. Under these laws, Freedom House may not say to any person outside Freedom House that you receive services from us without your consent. Generally, Freedom House must get your written consent before we can release information about you.

Example: We must get your written consent before we can release information to your health insurer for payment.

You may cancel your consent in writing at any time. You cannot cancel consent for information that has already been released.

You have the right to obtain, upon request, a list of entities to which their information has been disclosed pursuant to the general designation.

Federal law allows us to release information without your written permission for the following:

1. If Freedom House has an agreement with an outside organization known as a qualified service organization or business associated to provide services to clients.
2. For research, audit, or evaluations.
3. To report a crime committed on Freedom House property or against Freedom House staff.
4. To medical personnel in a medical emergency.
5. To report suspected child or elder abuse or neglect; or
6. As allowed by a court order.

Request Restriction--You may ask us to limit certain uses or disclose your health information. Freedom House will consider your request but does not have to agree. If your request is granted, we will comply except in emergency situations. We cannot agree to limit uses or releases that are required by law.

Request Confidential Communications--You may let us know how and where you would like to be contacted. For example, you can ask that we contact you by phone rather than mail or at work rather than at home. Your request must be in writing. We will go along with reasonable requests. We will not ask you for a reason.

Inspect and Copy--In most cases, you have the right to see or request copies of your records. You must make your request in writing using the Freedom House Consent for Release of Information" form. You may be charged copies for your records.

Amend/Correct--You may ask us to change the information in your records if you think there is a mistake. However, we will not erase the original information. You must make a written request that explains your reason(s). We do not have to agree to your request for changes if we determine, among other things, that the current information is correct and complete.

An Accounting of Disclosures--You must ask for a list of persons to whom your health information has been released. We may charge for additional lists. We will tell you about the charges (if any) and allow you to withdraw or change your request.

A Paper Copy of this Notice--You must ask us for a copy of this notice at any time. State and Federal laws require us to keep your health information private and to give you this notice of our legal duties and privacy practices.

By law, we will follow the terms of this notice. We have the right to change this notice. Any changes will apply to the information we already have about you, as well as any future information. The notice contains an effective date.

You may complain to us, the Board of Directors, and/or the Department of Behavioral Health Services (DBHS) if you believe your privacy rights have been violated under state and federal law. You will not be penalized for filing a complaint.

To file a complaint with DBHS, contact a staff member at:
DBHS
305 South Palm Street
Little Rock, AR 72205
501-686-9164

If you have any questions about this notice or our privacy practices, please contact our Privacy officer at 479-968-7086.

FofF: Client Agreement-Admission to Treatment

By signing this agreement, you, the “Person Served,” agree that you will abide by all the rules and regulations of the Friends of Freedom House Treatment Program as stated below and in the Outpatient Behavioral Services Handbook. You further agree that any deviation, violation, or non-compliance from any policy, rule, or regulation could be subject to immediate discharge or dismissal from the Program.

1. You will abide by all the rules and regulations of the Handbook, as you have been issued a copy and it has been explained to you.
2. Failure to comply with any rules and regulations of this program could be grounds for immediate dismissal.
3. This is a tobacco-free facility, and you are prohibited from smoking on campus.
4. Friends of Freedom House reserves the right to search any property owned by Friends of Freedom House and any property of yours for the purpose of detecting drugs, firearms, weapons, over the counter drugs, alcohol, syringes, or any other illegal object that is on Friends of Freedom House premises. By signing this agreement, you are aware and acknowledge that you are subject to personal belonging searches at any time, with or without prior notice to you.
5. You are prohibited from buying, selling, using, or loitering of any kind of drugs, alcohol, or mind-altering substances while a client at this facility. We reserve the right to conduct drug screenings at any time, with or without prior notification.
6. Outpatient clients and Residential clients are not to speak to, fraternize with (flirt), or come in contact with each other at any given time.
7. You must be respectful to all persons on and off the property. By signing this agreement, you agree that you will behave in a respectful manner to all Friends of Freedom House staff, persons served, and visitors. Your attitude toward yourself and others is a very important part of your recovery. You should always treat others will respect and dignity.
8. Loud music is prohibited at all times.
9.Friends of Freedom House does not allow weapons of any kind on its premises.
10. If you are dissatisfied with any part of the program or have a complaint, you agree to first discuss it with my counselor. If satisfaction cannot be reached, you understand that you may take my complaint to the Grievance Counselor, who will outline the steps of filing a complaint/grievance. If your situation still remains unsatisfied, you may submit your complaint to The Office of Alcohol and Drug Abuse Prevention, 305 South Palm Street, Little Rock, AR 72205 or call 501-626-9866.
11. You understand that Friends of Freedom house will not be responsible for any medical costs involving emergency room, hospital, hospitalizing, doctor’s fees, or treatment or referrals for treatment of any medical condition.
12. You also authorize Friends of Freedom House staff to assist you in receiving adequate medical attention if it is deemed necessary by treatment staff at your own expense.
13. You understand that Friends of Freedom House is required by law to report child abuse/child neglect or any other reported violent crimes committed or in the process of committing to Child Protective Services or Local Authorities.
14. You understand that as a Person Served, you have certain rights that are listed in the Outpatient Behavioral Services handbook, and they have been explained to you. You will take an active part of the formulation of your Individual Treatment Plan and After Care Plan. You understand that you will be given treatment, which is free of mechanical restraints. You further understand that you have the right to confidential treatment and do hereby authorize Friends of Freedom House to provide such.
15. Friends of Freedom House will not be responsible for any personal belongings if left behind after your departure.

I have read, or have had read to me and completely understand the rules and regulations of this agreement and the Friends of Freedom House Programs. I further understand that it is my responsibility to carry out any obligations and requirements that come with this agreement in order to remain in the program.

I understand that any deviation, violation, or non-compliance from any policy, rule, or regulation could be subject to immediate discharge or dismissal from the Program.

 

 

Referral for HIV/STD/AIDS, TB, Hepatitis Education, Testing, and Counseling Services

Why test? According to the CDC, an estimated one out of four HIV-positive Americans is unaware of their infection. Awareness of HIV infection leads to substantial reductions in high-risk sexual behavior. People who are infected with HIV but not aware of it are not able to take advantage of the therapies that can keep them healthy and extend their lives, nor do they have the knowledge to protect their sex or drug-use partners from becoming infected. Knowing whether one is positive or negative for HIV confers great benefits in healthy decision making. Injection drug users (IDUs) are at risk for hepatitis B virus (HBV) and hepatitis C virus (HVC) infection through the sharing of needles and drug-preparation equipment. In addition, outbreaks of hepatitis A infection have been reported among IDUs; such outbreaks are believed to occur through both percutaneous and fecal-oral routes. The Advisory Committee on Immunization Practices recommends that IDUs get vaccinated against hepatitis A and B. Because of higher rates of infection among this population, CDC also recommends testing for IDUs for chronic HBV infection.

Persons should get tested for TB by their doctor or local health department if they:

• Have spent time with a person known or suspected to have active TB disease;
• Have HIV infection or another condition that weakens the immune system and puts them at high risk for active TB disease.
• Have symptoms of active TB disease
• Live somewhere in the U.S. where active TB disease is more common such as a homeless shelter, migrant farm camp, prison or jail, or some nursing homes
• Inject drugs

I authorize the release of any medical information necessary to process insurance or payment claims for alcohol and substance use disorder treatment provided to me by ARVAC Inc. dba Freedom House. I also authorize payment of benefits directly to Freedom House for services provided to me.

All co-payments and deductibles must be paid upon entry and at the time of service. I understand that this arrangement is part of my contract with my insurance provider. I also understand that it is my responsibility to ensure that the services provided to me are paid either by my insurance provider or by me. If my insurance provider fails to make a payment or denies payment for services, it is my responsibility to pay for services in full. Payments are accepted by money order, check, or credit card.

 

I understand that if my insurance does not cover the entire cost of treatment, I will be responsible for such payment of services.

Freedom House has adopted a resolution system designed to ensure fair consideration and quick resolution of complaints and/or grievances made by or on behalf of the Persons Served.

Who may file a grievance – Any Person Served, or any person interested in the welfare of a person receiving services from Freedom House may file a grievance.

What complaints are considered – The grievance may be about any rule, policy, action, decision or condition at Freedom House, an employee, or any other person paid by Freedom House that relates to a violation of your rights.

When a grievance may be filed – Persons served are asked to first discuss their complaint with their appointed counselor. If the problem cannot be resolved in this manner, the person can submit their grievance on the Complaint/Grievance Form to the Grievance Officer, Dr. Kathleen Wallace. It is important that grievances be made following the grievance procedures in the policy and procedures manual as soon as possible and no later than forty- eight (48) hours following the incident that has led to the grievance.

How to file a grievance – Ask any Freedom House employee for a grievance form. Write your complaint on the form and include your resolution of the problem. Sign the form and return it to your primary Counselor.

What happens after you file a grievance – Within forty-eight (48) hours after your grievance is filed an attempt will be made, with your participation, to resolve the problem. You have a right to receive a written response to your grievance and to appeal if you are not satisfied with the response. You may appeal the decision to the Grievance Officer and then to the Freedom House Chief Compliance Officer (CCO). If the issue is not resolved by the CCO, you may appeal the decision to the ARVAC Chief Executive Officer and then to the Board of Directors.

If upon completion of this process, you are still unsatisfied, you may submit a grievance to the:

Department of Human Services
Division of Behavioral Health Services
305 South Palm Street
Little Rock AR. 72205
Telephone: 501-686-9164
Fax: 501-686-9182

 

I acknowledge that this Grievance Process has been explained to me and that I have received a copy. I fully understand the process of filing a grievance.

I understand the following:

• My participation is voluntary.
• If I agree to participate, I will be asked to verify my identity if the staff person identified above contacts me by telephone. There is always the potential risk that other persons with access to my telephone number or e-mail may find out about my participation in Freedom House services.
• I may withdraw my consent and discontinue participation any time without prejudice to my future services, except to the extent that action has been taken in reliance on it.
• This consent shall remain in effect commencing on the date of my discharge and expire one year thereafter, unless revoked in writing and delivered to Freedom House, Inc.

I understand the information provided and I was given an opportunity to ask questions and all my questions were answered to my satisfaction, and I was given a copy of this form.

By signing this agreement, you, the “Client,” agree that you will abide by all the rules and regulations of the Freedom House Treatment Program as stated below and in the Client Handbook. You further agree that any deviation, violation, or non-compliance from any policy, rule, or regulation is subject to immediate discharge or dismissal from the Program.

War Stories:

War stories are strictly prohibited while attending medication-assisted treatment. War stories include glamorization of alcohol/drug use, bragging about behaviors while using; generally talking about how much fun you had while in active addiction. This is dangerous and unproductive; They may trigger you or other clients to return to using; This will not be tolerated.

Cell Phones:

Cell phones are permitted within our facility for emergency use only. Please have your cell phones on silent or off and put in the location provided during all appointments or make arrangements to leave them in your personal vehicle. No recordings, videos, photos, or sharing of photos allowed.

FH is not responsible for lost, stolen, or broken property. Outpatient clients are not permitted to make or receive any phone calls from any client currently in residential treatment.

Physical Contact and Language:

Physical contact with our clients is strictly prohibited. Fighting, threatening, and aggression towards staff, clients, or visitors are grounds for immediate discharge. No profanity allowed.

 Rules and Regulations Overview:

All clients have access to a copy of this Client Outpatient Handbook. Familiarize yourself with the information in this handbook. If you have any questions about any of this information, please ask any staff for clarification.

Rules are a set of instructions and guidelines to help guide client behavior. They are important for maintaining order and structure. It is your responsibility to not only follow the rules outlined here but to also hold others accountable when they are not following the rules.

 Please note that any rules outlined in this handbook can be changed as deemed necessary. FH will do our part to make sure that any time a rule is changed; you are made aware so that you can adjust your behavior accordingly. There are times when a policy is not working the way it was intended. For this reason, we reserve the right to adjust to your needs as well as the needs of the staff and the program as a whole.

Firearms:

Firearms or other dangerous weapons are not allowed within Freedom House Facilities. Persons with a Concealed Handgun License are not allowed to bring a firearm on the Freedom House campus. However, law enforcement or security personnel in the performance of their duties may carry firearms within this facility.

Dress Code:

All clients are to dress in a manner that is dignified and presentable in public.

• All attire is to be modest
• Sagging is not allowed
• Shoes must be worn at all times
• Clean clothing will be worn
• Clients cannot wear sunglasses in the building
• All clients will wear appropriate undergarments at all times
• Clothing worn to bed (sleepwear) may not be worn
• Appropriate length shorts (no shorter than just above the knee) are allowed in suitable weather conditions

 Tobacco Use:

Freedom House is a tobacco-free facility (including electronic cigarettes). The use of tobacco products in the building or on the grounds of the campus is strictly prohibited.

 Protection of Valuables:

• Freedom House is not responsible for client property.
• Clients are not allowed to lend/borrow or give personal property to other clients.
• Financial dealings between staff and clients are strictly prohibited.

 I have read, or have had read to me and completely understand the rules and regulations of this agreement and the Freedom House Programs. I further understand that it is my responsibility to carry out any obligations and requirements that come with this agreement in order to remain in the program.

I understand that any deviation, violation, or non-compliance from any policy, rule, or regulation is subject to immediate discharge or dismissal from the Program.