Cirque Lodge Resident Admission Agreement
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I understand that I have a duty to maintain the confidentiality of all persons residing in Cirque Lodge. I also agree that I have a responsibility to respect the need for confidentiality around information that is revealed by other residents in groups or personal conversations. This confidentiality means that I will not reveal names of other residents, resident’s family members or any information they reveal to me. That includes my family, friends and others. I ask my peers to have the same obligations to respect my right to confidentiality. I understand that I am subject to discharge if I violate this agreement while a resident at Cirque Lodge I acknowledge that I have understood the Summary of Federal Regulations regarding confidentiality of alcohol and drug abuse patient records. Further, I understand that for my protection and the protection of other Residents, warranted, unannounced searches for contraband may be made.
Signed By: on date:
The undersigned does hereby apply for admission as a resident of Cirque Lodge. By accepting the resident at the facility, Cirque Lodge does not warrant or agree to effect a cure but does agree to accord the resident such medical care and treatment for alcoholism and/or addiction as will provide him/her the maximum opportunity for recovery. The practice of medicine and the treatment of addiction are not exact sciences, and no guarantee can be made to the results of the treatment. The following conditions and provisions shall govern the treatment, care and accommodations provided to all residents at the facility. Only the Board of Directors can modify, change or revise any of these conditions and provisions. The undersigned hereby applies for admission as a resident of Cirque Lodge. Cirque Lodge does not promise or agree to effect a cure but does agree to accord the resident such treatment for alcoholism and/or addiction as will provide resident the maximum opportunity for recovery. The practice of medicine and the treatment of addiction are not exact sciences and no guarantee can be made as to the results of the treatment. The following conditions and provisions shall govern the treatment, care and accommodations provided to all residents at Cirque Lodge. The resident agrees to conform to the rules and regulations of Cirque Lodge.
The undersigned accepts the terms hereof, certifies that he/she has read the foregoing, has received a copy hereof, and is the resident, or is authorized to sign as resident’s agent.
BEHAVIOR THAT CAN RESULT IN EARLY DISCHARGE OR TRANSFER FROM CIRQUE LODGE: Our goal at Cirque Lodge is for you to have a successful treatment experience. We need to inform you that there are behaviors that could interfere with your recovery and might result in discharge or transfer and forfeiture of monies on deposit. We ask that you read and understand what those inappropriate behaviors are. We encourage your questions. We want to ensure that all residents are provided with a safe environment that is conducive to recovery.
The following list of behaviors may lead to discharge or transfer to another facility:
I have reviewed the list of inappropriate behaviors, and I understand and agree that if l behave inappropriately, I may be discharged or transferred, and will forfeit any monies paid to Cirque Lodge.
Cirque Lodge programs involve a variety of activities that often include warm-ups, games, and group initiative problems and low and high ropes course elements. The level of participation in a program activity is at all times completely up to the participant that he/she may suffer an emotional or physical injury, disability or death. Every participant in Cirque Lodge programs is required to have health/accident insurance coverage. In addition, certain health/medical information must be made known to the instructor(s) conducting the programs so that they are prepared to respond appropriately if the need arises. This information will be held in confidence.
Do you have any limiting physical or mental disabilities or medical restrictions (temporary or permanent) that could present a hazard to yourself or others during the duration of this program?
If yes, identify and explain:
RELEASE OF LIABILITY I understand that parts of the Cirque Lodge program may be physically or emotionally demanding. I affirm that my health is good, and that I am not under a physician’s care for any undisclosed condition that bears upon my fitness to participate in activities. I understand that each participant must assume the risk of physical injury that could result from any of these activities. I release Cirque Lodge, and its staff members, from all liability for any injury to me from participation in Cirque Lodge activities. I understand that these terms shall serve as a release of liability for my heirs, executors, administrators and for members of my family. I have carefully read this Disclosure and Release of Liability and fully understand its content.
HEALTH INSURANCE COVERAGE DISCLAIMER Cirque Lodge is not responsible to verify insurance coverage, pre-certify, or give any indication of benefits that may or may not be available for residential care. Verification of coverage and pre-certification is the responsibility of the resident and should be done prior to the resident’s admission. Upon written request Cirque Lodge will provide residents with a copy of their billing statement. Cirque Lodge does not guarantee any payment in any amount by a resident’s insurance provider.
INSURANCE AGREEMENT I agree that upon discharge, unless otherwise directed in writing, Cirque Lodge may bill my insurance company for Cirque Lodge’s usual and customary fees. I understand that billing my insurance company is not a guarantee of payment.
If my insurance provider reimburses me for my treatment at Cirque Lodge, I agree that I am not entitled to keep any money until Cirque Lodge has been reimbursed for its entire usual and customary fees. If my insurance provider sends any payment directly to me for my treatment at Cirque Lodge, I will endorse and deliver such payment to Cirque Lodge immediately upon receipt.
BILLING PROCEDURE I agree, that upon discharge, Cirque Lodge may bill my insurance company for total charges including but not limited to Cirque Lodge’s usual and customary fees. I understand that billing my insurance is NOT a guarantee of payment. Upon written request Cirque Lodge will provide me with a copy of my billing statement.
I have read and understand the Protected Health Information (PHI) Notice of Privacy Practice. I agree and authorize Cirque Lodge Staff to sign for and transfer any medications from Harmon’s Pharmacy. I understand that if I do not authorize Cirque Lodge staff to order medications prescribed that I may be discharged from the Cirque Lodge Treatment Program. I understand that Cirque Lodge must acquire all medications through a known, trusted, and local pharmacy. As such, once I have met with the Medical Director, any medications prescribed for me must be ordered through one of these pharmacies and any medications brought from home will be mailed home at that time. I have read and understand the Protected Health Information (PHI) Notice of Privacy Practice. Further, I agree and authorize Cirque Lodge to contact and schedule medical appointments as needed, to be in compliance with JCAHO and Utah State Law.
I authorize Cirque Lodge to release information regarding emergencies and/or changes in my status to:
Emergency Contact, who is resident’s
ANY DISCLOSURES OF RECORD INFORMATION IS PROHIBITED BY FEDERAL REGULATIONS
I understand that I may revoke this consent for release of information at any time; however, I also understand that any release which has been made prior to my revocation and which was made in reliance upon this authorization shall not constitute a breach of right to confidentiality. If no date of revocation is specified, this consent shall expire ninety (90) days from the date of signature below. I certify that this request has been made freely, voluntarily and without coercion.
I acknowledge that Cirque Lodge has the right to search my belongings at any time for illicit or contraband items as determined by the program with or without prior notification or my presence. Cirque Lodge is not responsible for replacement of stolen or damaged property, valuables, money, credit/debit cards or checks.
Cirque Lodge will keep up to $500.00 cash in the safe on site. It is advised that any other valuables not kept on my person 24 hours a day should be sent home. If I choose to keep these items here I am personally taking responsibility for them should anything happen to them. By signing, I am acknowledging that I understand the personal belongings and safe policy and do not hold Cirque Lodge responsible for any of my personal belongings.
I have also received my Resident ID Number and was allowed a phone call to advise my family that I arrived and that there is a 72 hour communication blackout. I will be allowed normal phone use within standards of the program once the blackout is lifted. I acknowledge that regular computer use is not allowed outside of times set aside with my counselor until I reach the appropriate level within the program to use a computer alone. Further, I acknowledge that use of any personal laptops, tablets, or cell phones is generally prohibited even if I attain advanced level status. If brought in to the facility and I choose to not send them home, these items will be kept in a secure room open only to staff. As noted above, I acknowledge that Cirque Lodge is not responsible for replacement of damaged property I have chosen to keep here but which must be secured out of my possession.
THIS IS A LEGALLY BINDING AGREEMENT. In consideration of my being accepted to participate in the therapeutic program offered by Cirque Lodge, including but not limited to its program activities, I agree to the following waiver and release and make the following representations:
I have carefully read this Release of Liability and fully understand and agree to its contents, and sign it of my own free will.
Cirque Lodge and the resident understand and agree that all of the documents and forms set forth in this admissions package constitute one entire agreement (the “Agreement”). In addition to all of the agreements, authorizations, consents, disclosures, and releases set forth in this Agreement, the parties also agree to the following provisions:
This constitutes the entire agreement between the parties with respect to the subject matter. No modification, amendment or waiver of any of the provisions of this Agreement shall be binding upon Cirque Lodge or the resident unless made in writing and signed by both parties
Signed By: on date:
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Document Name: Cirque Lodge Resident Admission Agreement
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