Consents.v2

• I understand that buprenorphine/naloxone

  combination or buprenorphine mono-product

  is an opiate and has the same addictive

  properties as other opiates, such as hero

  in, methadone, codeine, morphine and OxyC

  ontin. Stopping buprenorphine/naloxone co

  mbination or buprenorphine mono-product s

  uddenly will result in the same withdrawa

  l symptoms and put me at the same risk of

  relapse as with other opiates.
• I agree to keep and be on time to all my

  scheduled appointments with the doctor. I

  f I am delayed or I must reschedule my ap

  pointment, I will notify the office in a

  timely way.
• I agree to conduct myself in a courteous

  manner towards all staff and other patien

  ts.
• I agree to provide urine for the purpose

  of toxicology screens at any time during

  my treatment.
• I agree to participate in group therapy a

  t the time of my appointment.
• I agree not to arrive at the office intox

  icated or under the influence of drugs.

  If I do, I will not be given medication u

  ntil my next scheduled appointment.
• I agree that my medication prescription c

  an be given to me only at my office visit

  s and only by the doctor. If I miss sched

  uled office visits, I may not be able to

  get a Suboxone prescription until the nex

  t scheduled visit.
• I agree to take my medication as the doct

  or has instructed and not to alter the wa

  y I take my medication without first cons

  ulting the doctor.
• I agree that the medication I receive is

  my responsibility and that I will keep it

  in a safe, secure place, away from child

  ren, pets or any person who could potenti

  ally abuse it. I understand that lost med

  ication will not be replaced.
• I agree not to sell, share, or give any o

  f my medication to another individual. I

  understand that such mishandling of my me

  dication is a serious violation of this a

  greement and would result in my treatment

  being terminated.
• I agree not to obtain any medications fro

  m any physicians, pharmacies, or other so

  urces without informing my treating physi

  cian. I understand that mixing buprenorph

  ine/naloxone combination or buprenorphine

  mono-product with other medications, esp

  ecially benzodiazepines (Xanax, Ativan, V

  alium, Klonopin), alcohol or other drugs

  of abuse, can be dangerous. I also unders

  tand that a number of deaths have been re

  ported among individuals mixing buprenorp

  hine/naloxone combination or buprenorphin

  e mono-product with benzodiazepines.
• I understand that medication alone is not

  sufficient treatment for my addiction, a

  nd I agree to participate in creating and

  carrying out a recovery treatment plan.

  This plan will be revised, with my input

  and as needed, to assist me in my recover

  y.
• If I decide to stop buprenorphine/naloxon

  e combination or buprenorphine mono-produ

  ct therapy at any time, I will work with

  the treatment nurse and doctor to taper s

  lowly (to reduce discomfort and relapse p

  otential) or to transfer to a methadone p

  rogram.
• SpecialistsMAT, PSC provides medical serv

  ices and treatment to patients with subst

  ance use disorder, and accordingly, it is

  a Qualified Service Organization as defi

  ned by the Confidentiality of Substance U

  se Disorder Patient Records law and regul

  ations, 42 USC § 290dd-2 and 42 CFR Part

  2 (“42 CFR Part 2”).

• When there is imminent danger to the pati

  ent or another person.
  
  
  Under circumstances of suspected child, e

  lder, or dependent adult abuse or neglect

  .
• When disclosure must be made to medical p

  rofessionals in the case of a medical eme

  rgency.
• When the mental health professional is co

  mpelled by law to disclose client records

  .

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.

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”).

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.

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.

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.

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.

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.