RCM APPLICATION FOR SERVICES & PRE-ADMISSION SCREENING

Are you a Veteran?

Are you currently homeless?

INSURANCE & ELIGIBILITY INFORMATION

(Used solely for insurance verification and billing purposes)

Primary Coverage:

This information is required only for Medicaid eligibility verification and is not used for clinical decision-making.

This information is accessed only by authorized admissions and billing personnel for eligibility verification and payment determination.

SAFETY & MEDICAL SCREENING
(Used to determine appropriate level of care and safe admission)
Primary substance(s) used in the past 30 days:

Are you currently experiencing withdrawal symptoms?

Have you ever experienced any of the following related to substance use:

Seizures?

Delirium Tremens (DTs)?

Severe withdrawal requiring hospitalization?

Are you currently taking prescribed medications?

Are you currently receiving Medication Assisted Treatment (MAT)?

Do you have any serious medical conditions that may affect participation?

Are you pregnant or possibly pregnant?

Do you require mobility, hearing, vision, or other accommodations?

PRIORITY & SPECIAL POPULATION SCREENING
Recovery Centers of Montana is required under state and federal regulations to identify certain priority and special populations for admission prioritization and reporting purposes. The information below is used to support coordination of care, regulatory reporting, and determination of appropriate level of care within the scope of services offered. Individuals who meet federally defined priority criteria may qualify for expedited placement in accordance with applicable regulations.

Are you currently pregnant?

If pregnant, are you currently using alcohol or drugs?

If pregnant, have you injected drugs at any time during this pregnancy?

Injection Drug Use

Have you injected drugs in the past 12 months?

Have you injected drugs in the past 30 days?

Women With Dependent Children (Reporting category)​​​​​​​

Are you a woman with dependent children under the age of 18?

Infectious Disease Status (For coordination of care and reporting purposes)​​​​​​​

Have you ever been diagnosed with active Tuberculosis (TB)?

Have you ever been diagnosed with HIV?

Have you ever been diagnosed with Viral Hepatitis (Hepatitis B or C)?

Have you ever been diagnosed with a sexually transmitted infection within the past 12 months?

LEGAL STATUS IMPACTING ADMISSION

Are you currently on probation or parole?

Do you have court dates within the next 30 days?

Are you required to register as a violent or sexual offender?

Are you involved in an active DFS case?

MENTAL HEALTH SAFETY SCREEN

Have you been hospitalized for mental health concerns within the past 12 months?

Do you have a history of suicidal behavior or attempts?

Are you currently experiencing thoughts of harming yourself or others?

SECTION 7: OPTIONAL DEMOGRAPHIC INFORMATION
(Voluntary – Used for State and Federal Reporting Only)
Providing this information is voluntary and will not affect eligibility for services.

Ethnicity:

Are you an enrolled member of a federally recognized tribe?

IMPORTANT ADMISSION NOTICE
On the day of admission, you must arrive sober and not intoxicated. If you arrive under the influence, admission may be delayed and you may be referred for medical evaluation.

CONFIDENTIALITY NOTICE
Recovery Centers of Montana is a federally assisted substance use disorder treatment program and complies with:

• 42 CFR Part 2

• HIPAA (45 CFR Parts 160 & 164)

• Applicable Montana Administrative Rules

Information provided in this application is used to determine eligibility, safety for admission, level of care, and payment verification.

Substance use disorder records are protected by federal law
(42 CFR Part 2) and may not be disclosed without written consent except as permitted by law. Redisclosure of this information is prohibited unless expressly permitted under 42 CFR Part 2.

Please indicate:

If assistance was provided: