4) I to give informed consent for the domiciliary staff to communicate with any agency or clinic from which I am receiving such medications. Such communications would be in an effort to coordinate the medical care provided for me. 5) I understand that I can only take medications, either prescribed or over-the-counter, that are prescribed or approved by Dom Medical Clinic while I am a resident of the Dom. Domiciliary Participation and Chronic Pain 1) I understand that, if I have chronic pain issues that make it difficult for me to adequately participate in either groups or classes or to focus on my treatment issues, I may be asked to discharge from the Dom until the pain issues are resolved and I can concentrate on my recovery program. 2) If I am discharged for that reason, I understand that I should further pursue my medical issues with a primary health care provider in an effort to stabilize my medical conditions. Dental and Eye Care 1) I understand VA dental resources are limited; services provided are on the basis of priorities and emergent in nature. 2) I understand that VA eye care resources are limited; services are provided on basis of priorities. 3) I understand that if I am 10% or greater "Service Connected" or have a medical condition or eye disease that needs monitoring, I may be provided with a routine eye examination and corrective eye wear while in the Domiciliary. Patient Signature_______________________________Date_____________________________ Attachment 2 DRRTP Statement of Acknowledgement As an applicant for the Northern Arizona VA Health Care System Domiciliary I am aware of and acknowledge the following: My application will be reviewed by the Domiciliary Screening Team. My acceptance into the Domiciliary will be determined on multiple factors which may include but are not limited to my previous treatment experiences, my medical and/or psychiatric needs, my ability to perform my own of daily living” (ADLs), my ability to live in a “activities group setting, my goals for employment and/or training, and the availability of beds. If accepted, I will, upon request, agree to a urine drug screen and breathalyzer prior to admission whenever requested by Domiciliary staff. and
4) I to give informed consent for the domiciliary staff to communicate with any agency or clinic from which I am receiving such medications. Such communications would be in an effort to coordinate the medical care provided for me. 5) I understand that I can only take medications, either prescribed or over-the-counter, that are prescribed or approved by Dom Medical Clinic while I am a resident of the Dom. Domiciliary Participation and Chronic Pain 1) I understand that, if I have chronic pain issues that make it difficult for me to adequately participate in either groups or classes or to focus on my treatment issues, I may be asked to discharge from the Dom until the pain issues are resolved and I can concentrate on my recovery program. 2) If I am discharged for that reason, I understand that I should further pursue my medical issues with a primary health care provider in an effort to stabilize my medical conditions. Dental and Eye Care 1) I understand VA dental resources are limited; services provided are on the basis of priorities and emergent in nature. 2) I understand that VA eye care resources are limited; services are provided on basis of priorities. 3) I understand that if I am 10% or greater "Service Connected" or have a medical condition or eye disease that needs monitoring, I may be provided with a routine eye examination and corrective eye wear while in the Domiciliary. Patient Signature_______________________________Date_____________________________ Attachment 2 DRRTP Statement of Acknowledgement As an applicant for the Northern Arizona VA Health Care System Domiciliary I am aware of and acknowledge the following: My application will be reviewed by the Domiciliary Screening Team. My acceptance into the Domiciliary will be determined on multiple factors which may include but are not limited to my previous treatment experiences, my medical and/or psychiatric needs, my ability to perform my own “activities of daily living” (ADLs), my ability to live in a group setting, my goals for employment and/or training, and the availability of beds. If accepted, I will, upon request, agree to a urine drug screen and breathalyzer prior to admission and whenever requested by Domiciliary staff.