FORMS
Required Forms
This release allows ARC Manor to verify insurance information through the Department of Human Services.
This release is for ARC Manor to discuss your treatment with your Primary Care Physician. If you do not have a PCP, just write “No PCP” in that section.
This release is for your Primary Care Physician to discuss your treatment with ARC Manor. If you do not have a PCP, just write “No PCP” in that section.
This release is for your emergency contact in case of a medical emergency.
This form is used to make sure that you know all of the different treatment agencies that you could attend. If you are choosing ARC Manor, please mark the different levels of care that ARC Manor offers. If you would like to go to another agency, please talk to your intake worker at getting your set up for an appointment with that agency.
This form focuses on your rights, confidentiality, and access to your records.
This is a consent to treatment that focuses on the risks and benefits of treatment as well as your responsibilities. It also includes telehealth informed consent.
This form discusses the attendance policy and financial responsibility.
This form is a risk screening for HIV, Hepatitis C, Tuberculosis. If you have any questions about HIV, Hepatitis C, or TB, please talk with your intake worker.
This form describes the process to file a grievance and appeal if unsatisfied with your services.
This release is for Quest Labs in case a drug screen needs sent for confirmation testing.
This release permits communication to Armstrong County Community Action in order to confirm appointments to secure Medical Assistance Transportation Program.
Additional Forms
This release is used to allow ARC Manor to share information about your treatment to other people or agencies. Some examples of who may want information about your treatment could include Probation, Attorneys, Magistrates, CYS. When completing the release, make sure to include the county as well as the agency (for example, Armstrong County Probation, instead of just Probation). For the purpose of the release, Coordination of Care is used for other people or agencies that would help with setting appointments or sharing information that could be important for your treatment; Monitoring Compliance with Treatment is used for legal issues such as probation; and Representation in Legal Case is used for your attorney. Only one agency per release.
This release is used to allow ARC Manor to share information about your treatment to probation/parole. When completing the release, make sure to only include the County that your probation/parole is in, not the probation officer’s name. Only one county per release.
This is a release that allows ARC Manor to give information to another treatment provider, such as a Mental Health Therapist/Psychiatrist, Suboxone Physician, or other type of doctor.
This release allows past clients to give authorization for ARC Manor to give information to another agency.
This release allows ARC Manor to bill your insurance company for your treatment.
This release allows ARC Manor to bill your insurance company for your treatment.
This release allows ARC Manor to bill the AICDAC for your treatment.
This release allows ARC Manor to bill your insurance company for your treatment. This is for those with medical assistance insurance from Clarion County.
This release allows ARC Manor to bill your insurance company for your treatment. This is for those with medical assistance insurance from Armstrong, Indiana, Butler, and Westmoreland Counties.
This form notifies any individual that is covered by Beacon Health Options the ability to file a grievance with that insurance company.
This release allows ARC Manor to provide referrals, if needed, to Armstrong, Indiana, Clarion Drug and Alcohol Commission’s case coordination office for you.
This release allows ARC Manor to provide referrals, if needed, to your county’s case coordination office for you.
This release is used when another agency needs a to have permission to give information to another agency, such as to ARC Manor. The first section is the name of the agency that will be giving the information about you and the next section is for the name of the agency that will receive your information from the first agency.
This form is used to approve audio/video recording for practicum/internship students for educational purposes. This is a voluntary consent and will not compromise ongoing treatment if you revoke or decline to sign.
This confidentiality form allows family members of ARC Manor residents to attend family group. The top section will require the name of your family member in our Residential program and the bottom section will require the visitor’s name.