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NOVA Recovery LLC Credit Card Authorization Form

Type of Card: (required) VisaMCAm ExDiscovery

Order/Invoice Number Order Description : NOVA Recovery LLC

This This Card is to be applied to:
Ancillary Account: Used to purchase medications (including co-pays), hygiene items and haircuts. Purchases over $20.00 the person listed on this authorization will be contacted for approval. This process is ongoing throughout the 90-day course of treatment, or as long as the individual is in our care or has an outstanding ancillary balance at time of discharge from care.

Treatment Cost: As agreed upon with the admissions team.

Amount to be Charged and Date(s) to be charged, as agreed upon with the Finance team, as applicable:

By signing this form, you authorize NOVA Recovery LLC to charge your card for the amount listed above, and you acknowledge that Nova Recovery, LLC has a no-refund policy with respect to treatment fees.

Cardholder's signature:

Buda Drug Store — Patient Information Form (NOVA)




Medication Allergies: YesNo

Buda Drug Store may release information in my records to health care providers, institutions, and or payers as may be necessary to facilitate care and/or process payment. I authorize Buda Drug Store to drop off prescriptions to NOVA and charge my credit card.

Informed Consent for Treatment

Briarwood Detox CenterNova Recovery Center

1) Condition to be Treated: As a client at Nova Recovery LLC, you will be treated for Substance Use Disorder. This is a preliminary diagnosis and may be changed as the clinical and medical staff (as warranted) further assesses you.

2) Recommended Course of Treatment/Treatment Process: The medical and clinical staff will assess your condition. The assessment process will include a physical examination, laboratory tests, personal interviews, and self-administered written evaluations. You will work with the clinical staff to determine the treatment plan you will follow while a client. Lengths of stay vary; however, the average stay is approximately 3-5 days (or until discharge deemed medically appropriate by Medical Director) in the detox program and/or ninety (90) days for clients in the residential treatment program.

3) Expected Benefits of Treatment: Although there are no express or implied guarantees on the quality of life you can expect after completion of treatment, many clients report a general improvement. These clients feel better equipped to deal with the conflicts/ problems that are a common part of normal living.

4) Probable Health & Mental Health Consequences of Not Consenting: Because of the progressive nature of Substance Use Disorder, it is reasonable to expect your condition to worsen without treatment. Specific consequences will depend on your situation and condition.

5) Side Effects & Risks Associated with Treatment: For some clients, early recovery poses challenges for the individual and/or the family members as they adjust to a new lifestyle. Part of treatment is gaining skills to deal with these challenges. The program is designed to minimize risks to your emotional or physical well-being. If you choose to leave the boundaries of the facility or become involved with activities that are unplanned or unsupervised by the staff, you may incur some unforeseen personal harm. You will not be expected to participate in activities for which you are not medically or physically appropriate.
There are clinical guidelines Nova Recovery Ll..0 utilizes to assess possible withdrawal severity, including the amount and duration of your alcohol and/or drug use; the severity of previous withdrawals (if any); and the presence of medical or psychiatric conditions. Through the assessment process, Nova Recovery LLC does take into account your medical history however, this cannot be considered totally reliable. The accuracy of the information you provide the physicians is a very important factor in lessening risks.
Possible side effects and risks associated with treatment include, but are not limited to:
a. Restlessness, irritability, anxiety, agitation
b. Tremor, elevated heart rate, increased blood pressure
c. Insomnia, intense dreaming, nightmares
d. impaired concentration, memory, and judgment
e. Delirium (disorientation to time, place, situation)
f. Hallucinations (auditory, visual, or tactile)
g. Delusions (usually paranoid)
h. Seizures

6) Alternatives to Treatment: Some people whose lives have been affected by substance use/abuse have been successful in outpatient counseling and/or twelve step programs. This may not be medically or otherwise appropriate for you, however, if you would like to discuss this or other options, please let a staff member know,

7) Qualifications of the Staff Providing Treatment: The professional staff at Nova Recovery LLC consists of Physicians, Psychiatrists, Licensed Chemical Dependency Counselors, Counselor Interns, Licensed Clinical Social Workers, licensed Professional Counselors and Medical Director.

8) Your Initial Counselor will be assigned to you. You may be assigned to an alternative Primary Counselor once your needs are assessed and you will be expected to participate in all program activities listed on the client schedule unless excused by the medical or clinical staff.

9) Client Grievance procedure has been explained to me, I have received a signed copy, and I understand the procedure.

10) The Client Bill of Rights has been explained to me, I have received a signed copy and I understand my rights as a client.

11) The Program Rules have been explained to me, I have received a copy in my client handbook, and I understand the program rules.

12) Violations that can lead to disciplinary actions have been explained to me during the review of program rules and I understand.

13) Searches of Client, Client Rooms and Property: Upon admission you, along with your personal belongings, will be searched. These types of searches may be conducted at any time throughout your treatment on a random or "for cause" basis. The use of personal searches and searches of your belongings are for your protection from illegal drug use or activity at the facility during your stay.
14) My Financial Obligations for Treatment (including the estimated daily charges, an explanation of any services that may be billed separately to a third party or to the client, based on an evaluation of the client's financial resources and insurance benefits) have been explained to me and I understand.

15) Nova Recovery LLC's Services and Treatment Process has been explained to me and I understand.

16) Family Involvement in Treatment: Sometime during your first few days of treatment you will be asked if there are any family member(s) or significant other(s) that you would like to attend the Family Program portion of your treatment with you. As a part of the assessment process, Nova Recovery LLC may contact one of those named in order to complete the Addendum to the Biopsychosocial Assessment. During these interviews, clinical information we have about you will not be disclosed without your written authorization. This is a normal part of building a baseline of information and aids the clinical staff in developing a comprehensive, individualized Treatment Plan.

Security Cameras: Video monitoring is conducted on Nova Recovery LLC's property. Video monitors will be utilized in certain client care areas, to ensure client safety and quality care. These cameras provide immediate viewing of current and daily activities. Viewing access for staff is strictly monitored.

Nova Recovery LLC Notice of Privacy Practices and Confidentiality has been explained to me, I understand, and I have received a copy.

My Responsibilities as a client have been explained to me, I understand, and I have received a copy.

It is our philosophy at Nova Recovery LLC that in order to provide you with the best possible care we must make it our priority to protect your individuality, dignity, and fundamental human, civil, constitutional, and statutory rights. Please be advised that your rights include the following:
(a) Nova Recovery, [IC shall respect, protect, implement and enforce each client right required to be contained in the facility's Client Bill of Rights. The Client Bill of Rights for all facilities shall include:
(1) You have the right to accept or refuse treatment after receiving this explanation.
(2) If you agree to treatment or medication, you have the right to change your mind at any time (unless specifically restricted by law),
(3) You have the right to a humane environment that provides reasonable protection from harm and appropriate privacy for your personal needs.
(4) You have the right to be free from abuse, neglect, and exploitation.
(5) You have the right to an environment that preserves dignity, respect, and contributes to a positive self-image.
(6) You have the right to appropriate treatment in the least restrictive setting available that meets your needs.
(7) You have the right to be told about the program's rules and regulations before you are admitted, including, without limitation, the rules and policies related to restraints and seclusion. Your legally authorized representative, if any, also has the right to be and shall be notified of the rules and policies related to restraints and seclusion.
(8) You have the right to be told before admission:
(A) the condition to be treated;
(B) the proposed treatment;
(C) the risks, benefits, and side effects of all proposed treatment and medication;
(D) the probable health and mental health consequences of refusing treatment;
(E) other treatments that are available and which ones, if any, might be appropriate for you;
(F) the expected length of stay; and
(G) what is to be expected of treatment.
(9) You have the right to a treatment plan designed to meet your needs, and you have the right to take part in developing that plan.
(10) You have the right to meet with staff to review and update the plan on a regular basis.
(11) You have the right to refuse to take part in research without affecting your regular care.
(12) You have the right not to receive unnecessary or excessive medication.
(13) You have the right to have information about you kept private and to be told about the times when the information can be released without your permission.
(14) You have the right to be told in advance of all estimated charges and any limitations on the length of services of which the facility is aware.
(15) You have the right to receive an explanation of your treatment or your rights if you have questions while you are in treatment.
(16) You have the right to make a complaint and receive a fair response from the facility within a reasonable amount of time.
(17) You have the right to complain directly to the Department of State Health Services at any reasonable time.
(18) You have the right to get a copy of these rights before you are admitted, including the address and phone number of the Department of State Health Services.
(19) You have the right to have your rights explained to you in simple terms, in a way you can understand, within 24 hours of being admitted.
(20) You the right to have your cultural and personal values, beliefs and preferences be respected.
(21) You have the right to amend personal health information and obtain information on disclosures of information, in accordance to law.
(22) You have the right. to have Nova define your rights when handling emergencies.
(23) You have the right to receive information in a manner you understand,
(24) Nova Recovery, LLC respects your right to collaborate in decision about care, treatment, and services.
(25) You have the right to give or withhold informed consent to produce or use recordings, films or other images of client for purposes other than your care.
(26) Nova Recovery, Ill. protects clients and respects rights during research, investigation and clinical trials.
(27) Nova Recovery, LLC respects the right of the person to receive information about the staff responsible for his/her care.

(b) For residential sites, the Client Bill of Rights shall also include;
(1) You have the right not to be restrained or placed in a locked room by yourself, If you become a danger to yourself or others, Nova Recovery staff will call 911.
(2) You have the right to communicate with people outside the facility. This includes the right to have visitors, to make telephone calls, and to send and receive sealed mail. This right may be restricted on an individual basis by your physician or the person in charge of the program if it is necessary for your treatment or for security, the reason, length of time, and removal of restriction will be explained and documented in the client chart, but even then you may contact an attorney or the Department of State Health Services at any reasonable time. Restrictions on communication will be reduced or eliminated when no longer therapeutic.
(3) If you consented to treatment, you have the right to leave the facility within four hours of requesting release unless a physician determines that you pose a threat of harm to yourself and others.
(4) Each facility promotes an awareness of day, time and season by clocks, calendars, outdoor recreational activities, outdoor sitting areas, and holiday events.
(5) You have the right to accommodate the right to pastoral and other spiritual services.

(c) If a client's right to free communication is restricted under the provisions of paragraph (b)(2) of this section, the physician or program director shall document the clinical reasons for the restriction and the.duration of the restriction in the client record. The physician or program director shall also inform the client, and, if appropriate, the client's consenter of the clinical reasons for the restriction and the duration of the restriction.

The effects of compliance with this policy ensures that client's rights and grievance procedures are understood by the clients and their applicable consenters and supporters. Clients that enter any LOC with Nova Recovery, LLC are voluntary clients, and have the right to receive and understand all required information. Nova Recovery, LLC staff shall always assist a client who has questions about their rights, filing a complaint or grievance, and/or their care.

Substance Abuse Facility Investigations (MC 1979)
Texas Department of State Health Services
PO Box 149347 TX 78714-9347
Toll Free: (800) 832-9623
Phone: (512) 834-6700

Client's Signature:

Staff's Signature:

Authorization for Emergency Medical Treatment

In the event of an emergency, contact:
Emergency Contact #1

Emergency Contact #2

Emergency Contact #3

In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the property of the agency, I authorize Nova Recovery LLC to:
1. Secure and retain medical treatment and transportation if needed.
2. Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.

Consent Plan
This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed "life saving" by the physician. This provision will only be invoked if the person(s) above is unable to be reached.

Non-Consent Plan
I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency.
In the event emergency treatment/aid is required, I wish the following procedure to take place:

Waiver of Liability and Hold Harmless Agreement

1. In consideration for receiving permission to participate in Cross Fit and Recreational Activities, I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE Nova Recovery LLC, their officers, agents, servants, or employees (hereinafter referred to as RELEASEES) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or any of the property belonging to me, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASES, or otherwise, while participating in such activity is being conducted.

2. I am fully aware of the risks involved and hazards connected with this activity, including but not limited to travel risks and/or risks involved in working with equipment. I hereby elect to voluntarily participate in said activity with full knowledge that said activity may be hazardous to me and my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF Loss, PROPERTY DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, which may be sustained by me, or any loss or damage to property, owned by me, as a result of being engaged in such an activity, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE.

3. I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS THE RELEASEES from any loss, liability, damage or costs, including court costs and attorney fees, that they may incur due to my participation in said activity, WHETHER CAUSED BY NEGLIGENCE OF RELEASEES or otherwise.

4. It is my express intent that this Waiver of Liability and Hold Harmless Agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE the abovenamed RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of Texas.

S. IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT that I have read the foregoing Waiver of liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements, or inducements, apart from the foregoing written agreement, I have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate and complete consideration fully intending to be bound by the same.

Signed on

Assignment of benefits

I hereby authorize and request that payment of authorized insurance company benefits be made on my behalf to directly to Nova Recovery LLC for the amount due to me for any medical or treatment or services that are rendered to me by Nova Recovery, LLC.

I authorize the holder of medical or other information to release the information needed or related to claims for services rendered to me by Nova Recovery, LLC to any necessary government agency, including but not limited to the Social Security Administration; Health Care Financing Administration, and to any insurance payer or provider in regards to my claims.

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