Consents.v2
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SIGNATURE / type your name (click on pen) Signature
SIGNATURE / type your name (click on pen) Signature
I authorize SpecialistsMAT to disclose to the State and/or local Department of Health officials that require the following reports:
(1) Information that State law requires to be reported about my diagnosis and treatment for: HIV infection, AIDS, STD (sexually transmitted disease), and TB (tuberculosis)
(2) My name and other personal identifying information, if required to be reported by State law;
(3) Information about my status as a patient in alcohol or drug treatment, if required to be reported by State law.
The purpose of the disclosure authorized herein is to allow my alcohol or drug treatment program to comply with State law(s) requiring the reporting of cases of HIV/AIDS/STD/TB.
I understand that my records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that HIV-related information about me, STD-related information about me, and TB related information about me is protected byState law and cannot be disclosed unless the disclosure is authorized by State law. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically 1 year from the date of this consent.
SIGNATURE / type your name (click on pen) Signature
In a medical emergency where your well being or safety is at risk, SpecialistsMAT, PSC has the permission to contact your emergency contact.
SpecialistsMAT, PSC provides medical services and treatment to patients with substance use disorder, and accordingly, it is a Qualified Service Organization as defined by the Confidentiality of Substance Use Disorder Patient Records law and regulations, 42 USC § 290dd-2 and 42 CFR Part 2 (“42 CFR Part 2”).
SIGNATURE / type your name (click on pen) Signature
BEHAVIOR POLICY / Code of Conduct
As a patient at Specialists/ Medication Assisted Treatment, you have made a voluntary decision to participate in this program. We seek to provide an optimum treatment environment for all patients. Patients are expected to maintain appropriate behaviors such as:
No dealing of drugs, stealing, or any other illegal or disruptive activities in the clinic environment, or on the grounds of the office complex.
No tampering with or falsifying urine toxicology tests.
No disruptive behavior i.e., loud, aggressive behavior, etc. will be tolerated in the clinic.
No verbal (including electronic) or physical threats towards anyone including: OBOT staff, clerical, pharmacy, other patients, etc. of any kind will be tolerated.
No possession or use of guns, knives, mace or harmful objects on clinic property.
Should any of these behaviors occur, it is grounds for immediate discharge from the program.
SIGNATURE / type your name (click on pen) Signature
ATTENDANCE POLICY
All patients who participate in the Specialist/ Medication Assisted Treatment OBOT program are required to keep all appointments with their primary care providers and OBOT providers. These appointments are critical to the continuation of care.
If an appointment cannot be kept, it is the patient’s responsibility to reschedule the appointment. This does not include random callbacks.
Patients are expected to arrive on time for all scheduled appointments. Appointments with providers may need to be rescheduled if patients arrive late.
If there are any changes in medications or medical issues including: surgery, medications, hospitalizations, or problems with a prescription please contact Specialist/ Medication Assisted Treatment at 502 212 0071 as soon as possible to address the situation. The patient may also use the patient portal at www.specialistsmat.com.
All prescriptions will be timed to the patient appointment.
Following induction with buprenorphine mono-product or with buprenorphine with naloxone, patients will be seen three times in the first month and two times per month for months 2 through 4 after induction. If the patient has been compliant with treatment, then the patient will be “graduated” to monthly visits.
If the patient presents to the OBOT as a transfer from another clinic and is on a stable dose of buprenorphine mono-product or buprenorphine with naloxone without any aberrant behaviors, the provider may use their professional discretion and decrease the time until the patient is “graduated” to monthly visits.
If the compliant patient becomes out of compliance, the provider may use their professional discretion and increase the frequency of visits until the patient returns to compliance.
Compliance means there are rules that our patients must follow to insure their success in our program. Compliant patients earn more privileges such as fewer appointments. Compliance can be measured by 3 simple metrics called the “ABC’s of Compliance”:
Attendance: Just show up! You can not get better if we cannot treat you.
Be Clean: Stop using illicit substances.
Counseling: Failure to participate in counseling will lead to failure.
SIGNATURE / type your name (click on pen) Signature
URINE TOXICOLOGY SCREENING POLICY
1) All belongings (coats, bags, etc.) are left outside the bathroom door.
2) No washing hands until the urine sample is handed to the medical assistant.
3) No flushing of the toilet until urine sample is handed to the medical assistant.
4) Urine samples will be required at each visit.
5) Any questionable urine sample is an automatic repeat the same day.
6) Observed urines are discouraged but may be necessary. Oral swabs may be utilized in place of observed urines.
7) Tampering of urine samples may be grounds for discharge and referral to a higher level of care.
SIGNATURE / type your name (click on pen) Signature
Prior Authorization
I give permission to SpecialistsMAT, PSC to submit authorization requests on my behalf, and if necessary, to appeal the denial of any ordered medications.
SIGNATURE / type your name (click on pen) Signature
SIGNATURE / type your name (click on pen) Signature
In order to provide you with the best possible care, SpecialistsMAT utilizes text messaging and email to facilitate communication and engagement with its patients. Text messages and emails may include appointment reminders, general inquiries regarding appointments and medications, and in office messaging to provide you with an efficient appointment experience. Text messaging and email are not secure forms of communication, but they are HIPAA compliant through the avoidance of individually identifiable health information in the transmitted messages. I understand that message/ data rates may apply to messages sent under my cell phone plan. For additional details regarding this policy, please direct your questions to a staff member.
SIGNATURE / type your name (click on pen) Signature
This release of information is intended to provide coordination of care between SpecialistsMAT, PSC and P/N Behavioral Health. You are givng SpecialistsMAT, PSC and P/N Behavioral Health the authority to share medical records and to speak with each other for the purpose of coordination of medical care and the treatment plan.
I authorize the SpecialistsMAT, PSC and P/N Behavioral Health to share or disclose all of my medical records, including any specially protected records, such as those relating to psychological or psychiatric impairments, substance use disorders, and medical or surgical treatments.
I authorize SpecialistsMAT, PSC and P/N Behavioral Health to coordinate care with professionals and health care delivery systems as clinically appropriate. Coordination of care may include treatment updates, psychotherapy notes, and laboratory findings.
If you do not want certain portions of your medical records released, please read this section carefully and identify the information you do not want released. Otherwise, your records will be released as specified above.
I understand that I may revoke the authorization at any time prior to the expiration date or event, but that my revocation will not have any effect on actions taken by SpecialistsMAT, PSC or its physicians, employees or agents before they received my revocation. Should I desire to revoke this authorization, I must send written notice to SpecialistsMAT, PSC.
I understand that I am not required to sign this authorization. SpecialistsMAT, PSC or its physicians, employees will not condition treatment, payment, enrollment or eligibility for benefits on whether I provide this Authorization.
I understand that my records may be subject to disclosure by the recipient and may no longer be protected by federal privacy regulations. I understand that this Authorization does not limit SpecialistsMAT, PSC or its physicians, employees its physicians’, employees’ or agents’ ability to use or disclose my information for treatment, payment, or health care operations, or as otherwise permitted by law.
This release of information expires in 1 year after signature date.
SpecialistsMAT, PSC provides medical services and treatment to patients with substance use disorder, and accordingly, it is a Qualified Service Organization as defined by the Confidentiality of Substance Use Disorder Patient Records law and regulations, 42 USC § 290dd-2 and 42 CFR Part 2 (“42 CFR Part 2”).
SIGNATURE / type your name (click on pen) Signature
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