DIP REGISTRATIONS

Bloom Recovery Network, LLC Authorization For Disclosure Of Confidential SUD Patient Records
I,
authorize Bloom Recovery Network LLC to disclose: Registration letter, attendance or lack of attendance, participation (understanding of objectives, behavior/response), cooperation with the DIP program rules and expectations, Program Completion Report, Certificate of Completion
Is there specific information you want disclosed?
[describe how much and what kind of information may be disclosed, including an explicit description of any substance use disorder information to be disclosed; should be as limited as possible]
TO*
Type the name of your sentencing court.
Please provide contact information if disclosure for Attorney or other referring agency:
(only place attorney information in this box if your disclosure is going to an attorney versus a court)
For the purpose of informing the criminal justice agency(or other) listed above of MY DRIVER'S INTERVENTION PROGRAM compliance or non-compliance.
[describe the purpose of the disclosure; should be as specific as possible]
This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is not sufficient for this purpose (see 42 CFR 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at 42 CFR 2.12(c)(5) and 42 CFR 2.65.
I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire automatically as follows:*

there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment/prevention (DIP) OROther
If selected "other" above:
[date, event, or condition upon which consent will expire, which must be no longer than reasonably necessary to serve the purpose of this consent]
I understand that I may be denied services if I refuse to consent to disclosure for purposes of treatment, payment, or healthcare operations, if peremitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.

I have been provided a copy of this form.
Signature of defendant/client:*

Clear
By signing above, I agree that the signature will be an electronic representation of my signature for all purposes when I use them on this document.
Signature of person signing form if not patient:

Clear
By signing above, I agree that the signature will be an electronic representation of my signature for all purposes when I use them on this document.
IF SIGNING ON BEHALF OF THE PATIENT:
Describe authority to sign on behalf of patient

Bloom Recovery Network-72hr DIP Rules & Expectations
Bring clothes and personal hygiene materials to meet your needs for three days and three nights. Appropriate dress is expected (no cutoffs, tank tops, shirts with obscene slogans, short shorts, or headgear). Pajamas may not be worn outside of your room. You are to be showered and appropriately groomed.

1. REGISTRATION & CHECK IN will be in the conference room beginning at 4pm. BE PROMPT. Latecomers will not be admitted and will forfeit payments made. An inspection of all personal possessions will be made upon reporting, including emptying all pockets. NOTE: Personal property is subject to search at any time. Be sure to bring photo identification.

2. ONCE CHECKED-IN, no one is allowed to leave the program site.

3. REPORT SOBER, FREE OF DRUGS AND IN GOOD HEALTH. You will not be admitted if you report to the program while under the influence of alcohol or drugs (verified by staff’s reasonable suspicion and/or drug testing). DO NOT DRINK ALCOHOL OR USE RECREATIONAL DRUGS 24 HOURS PRIOR TO COMING TO THE PROGRAM. Possession of drug paraphernalia will also result in immediate discharge. Drugs and drug paraphernalia will be confiscated and turned over to law enforcement.

4. YOU MAY BRING SNACKS, but they are to be in sealed containers. No opened containers of any kind will be permitted once a client begins the intake process. The program is not required to offer food on the first day so eat before you check in. Please bring change for vending machines as there will be limited change available.

5. Clients who have a SPECIAL DIETARY REQUIREMENT (FOR FOOD ALLERGIES, GLUTEN-FREE DIETS, VEGETARIAN/VEGAN DIETS, and RELIGIOUS DISTINCTIONS) will be accommodated; however we are only able to provide a limited selection. Clients who seek a certain meal plan and/or diet are encouraged to bring additional snacks/meal prep for their specific requirement. We will NOT ACCOMMODATE meal PREFERENCES. a statement that Bloom Recovery does not consider food preferences but will make adjustments based on food allergies, gluten-free, vegetarian, low salt, and religious distinctions only

6. PRESCRIPTION & NONPRESCRIPTION DRUGS must be in the original container, with the correct label. Only bring the required amount needed for a 72-hour period. Medical emergencies will be referred to the emergency room of a local hospital.

7. CIGARETTES, TOBACCO & VAPES are allowed only during specified break times. Violation of Cigarette/Tobacco/Vape policy is grounds for termination from the program and a $250 fine. Please bring enough cigarette/tobacco/vape products to last through the DIP event. No deliveries of this type will be permitted. Vapes: Only brand new, unsealed vape pens/mods will be permitted. Due to previous suspected misuse of these products, vape products that are not in the original sealed package and have been previously used WILL NOT BE PERMITTED. Vapes are only allowed during specific break times. You are not permitted to vape in your hotel room, violation of this policy is grounds for termination from the program and a $250 fine.

8. MEDICAL MARIJUANA is only permitted if you have a valid prescription card and it is brought in gummy form. No vape pens/mods with medical marijuana will be allowed. The medical marijuana gummy will be treated as medication and will be administered as such.

9. ANY BREACH OF CONFIDENTIALITY will result in immediate dismissal. This includes sharing other client names and/or information they share, pictures of persons in attendance, as well as, sharing with other hotel guests as to why you are in the program.

10. USE OF THE HOTEL PHONE is not permitted. If incidental charges are billed to your room, your participation in the DIP will be voided. You are not to approach the front desk or any hotel staff during the 72-hour intervention program.
11. YOU ARE TO OBEY ALL RULES of the hotel and respect hotel property. You are not to remove any items from the hotel room. You are expected to keep your room clean and in order during the weekend. Bloom Recovery DIP have the right to enter and search rooms at any time.
12. DURING SUPERVISED FREE TIME (usually 9pm-10pm) clients are allowed to be in the lobby, fitness center, business center, designated smoking area, or their own rooms. Under no circumstance is a client allowed to go into the parking lot or another person’s room. At 10pm clients must be in their rooms for bed check at which time room keys will be collected. Those not present at this curfew check will be considered AWOL. No loitering in the hallways. Staff must know where you are at all times.

13. WE UNDERSTAND THE NEED FOR PEOPLE TO BE ABLE TO STAY IN CONTACT WITH FAMILY & FRIENDS, therefore, cell phones are allowed but can only be used in your room and during specified break times. During class sessions, phones are to remain OFF and/or may be collected. At staff discretion, cell phones may be collected at night and returned in the morning. NOTE: Upon staff discretion, vehicle keys could also be collected and returned at discharge. You are responsible for your phone; therefore, we advise you not to loan out your phone. You are also responsible for charging your phone. Phones may not be charged in the conference room. You may bring laptops, iPad or similar. However, those items are to always be kept in your room. Bloom Recovery Network, LLC is not responsible for any lost, stolen or damaged phones, laptops, iPad, etc.

14. KEEP ALL VALUABLES with you. The DIP does not assume responsibility for any property that is left in your hotel room. Notify DIP security personnel or Program Director immediately of any room damage or malfunction.

15. NO PERSONAL DELIVERIES will be permitted without approval from the staff (from family members/friends/other visitors). Food deliveries from food establishments, Uber Eats, DoorDash (or similar) allowed during all mealtimes and free time.

16. GAMBLING of any form is prohibited.

17. VISITS FROM FAMILY/FRIENDS WILL NOT BE PERMITTED. Please inform family/friends of these rules.

18. YOU ARE RESPONSIBLE FOR GETTING YOURSELF UP ON TIME. You are to arrive at all sessions on time. You are not to leave the group unless given permission.

19. TO PROTECT YOURSELF, alert staff immediately if your roommate violates this policy.

20. NO KNIVES, GUNS, OR WEAPONS of any kind are allowed. If you bring them, they will be confiscated.

21. While Bloom Recovery understands the onset of unexpected events and/or emergencies - we have a specific CANCELLATION/RESCHEDULING policy that all clients will adhere to. Please refer to this policy via bloomrecoverynetwork.com or ask a staff member for a copy.

22.TOLEDO (Perrysburg) CLIENTS: Participants are required to wear a bracelet at all times. You will be provided with the bracelet at intake. Removal of the bracelet could result in termination from the program. You will have access to the hotel pool but only during specified break times. Hotel pool rules are to be honored while making use of the pool. Appropriate swimwear is required. No lifeguard on duty. Swim at your own risk.

You are a guest of Bloom Recovery Network’s DIP. You will be fully respectful of all individuals with whom you encounter. In turn, you will be treated with respect. Any harassment or behaviors perceived to be threatening, including sexually oriented remarks, sounds, and gestures, will not be tolerated. Any deliberate or negligent actions harmful to the safety or welfare of clients or staff will result in immediate discharge and legal action may be taken if deemed appropriate. Any behavior or action which may compromise the integrity of the program will result in immediate discharge. The program reserves the right to dismiss a participant who is not suited for the DIP, as demonstrated by actions of unruliness, or infringement of any of the above stated rules. IF YOU ARE ASKED TO LEAVE FOR ANY RULE VIOLATION, YOU WILL NOT BE REFUNDED. YOUR REFERRAL SOURCE WILL BE IMMEDIATELY NOTIFIED INCLUDING THE REASONS FOR DISMISSAL.
SIGN BELOW FOR ACKNOWLEGEMENT OF READING THE PROGRAM RULES & EXPECTATIONS.
Signature of defendant/client:*

Clear
By signing above, I agree that the signature will be an electronic representation of my signature for all purposes when I use them on this document.

Bloom Recovery Network Intake Form

Emergency Contact

YOU ARE NOT CONSIDERED REGISTERED UNTIL DEPOSIT IS PAID. ONCE PAYMENT IS RECEIVED, ALONG WITH THE INTAKE & CONSENT FOR RELEASE; WE WILL CONTACT THE COURTS.

Bloom Recovery Network, LLC Authorization For Disclosure Of Confidential SUD Patient Records

I,

Bloom Recovery Network-72hr DIP Rules & Expectations

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