Welcome to SpecialistsMAT

As a participant in the Medication Assisted Treatment protocol for treatment of opioid abuse and dependence, I freely and voluntarily agree to accept this treatment agreement/contract, as follows: 

• I understand that buprenorphine/naloxone combination or buprenorphine mono-product is an opiate and has the same addictive properties as other opiates, such as heroin, methadone, codeine, morphine and OxyContin. Stopping buprenorphine/naloxone combination or buprenorphine mono-product suddenly will result in the same withdrawal 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. If I am delayed or I must reschedule my appointment, I will notify the office in a timely way.  
• I agree to conduct myself in a courteous manner towards all staff and other patients.  
• I agree to provide urine for the purpose of toxicology screens at any time during my treatment. 
• I agree to participate in group therapy at the time of my appointment. 
• I agree not to arrive at the office intoxicated or under the influence of drugs.  If I do, I will not be given medication until my next scheduled appointment.
• I agree that my medication prescription can be given to me only at my office visits and only by the doctor. If I miss scheduled office visits, I may not be able to get a Suboxone prescription until the next scheduled visit.
• I agree to take my medication as the doctor has instructed and not to alter the way I take my medication without first consulting 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 children, pets or any person who could potentially abuse it. I understand that lost medication will not be replaced. 
• I agree not to sell, share, or give any of my medication to another individual. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated. 
• I agree not to obtain any medications from any physicians, pharmacies, or other sources without informing my treating physician. I understand that mixing buprenorphine/naloxone combination or buprenorphine mono-product with other medications, especially benzodiazepines (Xanax, Ativan, Valium, Klonopin), alcohol or other drugs of abuse, can be dangerous. I also understand that a number of deaths have been reported among individuals mixing buprenorphine/naloxone combination or buprenorphine mono-product with benzodiazepines. 
• I understand that medication alone is not sufficient treatment for my addiction, and 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 recovery.
• If I decide to stop buprenorphine/naloxone combination or buprenorphine mono-product therapy at any time, I will work with the treatment nurse and doctor to taper slowly (to reduce discomfort and relapse potential) or to transfer to a methadone program.
• 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”).

This release of information is intended to provide coordination of care between SpecialistsMAT, PSC and {recoveryFacility2}. You are giving SpecialistsMAT, PSC and {recoveryFacility2} 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 {recoveryFacility2} 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 {recoveryFacility2} 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.

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”).

SpecialistsMAT is committed to providing quality services. This consent addresses important information about service procedures and patient rights in regard to counseling services. A licensed professional counselor will explain this information to you during your initial visit. It is important for you to understand the policy information and treatment information identified below prior to the start of your group therapy sessions. 

PSYCHOLOGICAL SERVICES

Individual or group therapy can help individuals develop skills to enhance interpersonal relationships, behavior, emotional and mental health, coping skills, and self awareness. Individual or group therapy is designed so individuals can communicate and share experiences. This interactive quality allows for the development of trust. The therapy process may stimulate some uncomfortable feelings and emotions. Participation in therapy does not guarantee problem resolution. As with all medical and psychological treatments, there are benefits and risks. It is recommended that you be aware of all the risks and benefits prior to proceeding. If you have any questions, please ask your therapist at any time during the therapy process. 

APPOINTMENTS 

Individual or group therapy sessions are provided at every medical appointment and must be attended to satisfy compliance. Due to the importance of each member in the group dynamic, it is important for individuals to commit to the time periods identified. If you will have difficulty attending all sessions or need a modified schedule, please talk to the therapist.  Please be punctual. Each group has an allotted scheduled time. Tardiness may disrupt the start of the session, which will still need to end at the originally scheduled time. 

PROFESSIONAL FEES

SpecialistsMAT provides individual or group therapy counseling, and your insurance provider will be billed for the time spent in treatment. 

CONFIDENTIALITY

SpecialistsMAT is committed to following the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights regarding the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. All information, discussions, and documents are confidential and privileged information for all patients. Under federal law, disclosure of information regarding services provided and information about a patient requires written consent to release to alternate or third parties. 

The following are exceptions to the rules of confidentiality and will be understood by the patient involved. 

• When there is imminent danger to the patient or another person. 
  Under circumstances of suspected child, elder, or dependent adult abuse or neglect.
• When disclosure must be made to medical professionals in the case of a medical emergency. 
• When the mental health professional is compelled by law to disclose client records. 

SpecialistsMAT is a professional setting of mental health professionals. Treatment team members may, at times, consult with colleagues/ mental health professionals at SpecialistsMAT about your case. Your name will not be disclosed and your identity will be kept disguised. Consults will only be used for the betterment of your treatment. 

Treatment team members will adhere to the ethical and legal requirements of confidentiality. Each patient  is required to sign a confidentiality agreement; however, treatment team members can’t ensure that you or members of a group will maintain the same level of confidentiality.  

PROFESSIONAL RECORDS

Service providers are required, by law, to keep medical records of psychological services provided. All records will be secured in a locked location following Health Insurance Portability and Accountability Act (HIPAA) standards. Records include, but are not limited to, documentation of attendance; purpose of treatment; any medical, social, and treatment history; evaluations and diagnosis; anecdotal notes of topics and discussions; copies of legal forms and consents; documents and copies of any forms or information shared with other professionals; and information provided by other professionals.

EMERGENCY SERVICES

This clinic does not provide emergency services. Please call the office during regular business hours if you would like to schedule an appointment as soon as possible.  If you have an immediate emergency call 911 or visit your closest emergency room. 

PATIENT RIGHTS

You have the right to considerate, safe, and respectful care, in the absence of discrimination regarding race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy, therapist training, and therapist experience. You have the right to communicate your therapeutic needs if you feel dissatisfied or feel like any of the above mentioned rights have been violated in any manner. You have the right to request a change in service providers. In this case, your current service provider will assist in providing the needed information to the new service provider with written consent by the patient. 

TERMINATION OF TREATMENT

SpecialistsMAT has the right to terminate treatment at any time due to lack of payment, violations of its code of conduct, or a development that occurs outside the scope of our area of competence. In the case of termination, if needed, theSpecialistsMAT will support a transition to a service provider of continued care. 

Therapeutic counseling can result in changes in relationships, emotional state, and patient behavioral patterns.  There are circumstances that result in a lack of improvement. Under circumstances of extreme discomfort and emotional pain, the patient has the right to terminate or not continue services. 

CONSENT TO PSYCHOTHERAPY

I voluntarily agree to receive individual and / or group  therapy with the counselors and behavioral health professionals at SpecialistsMAT.  I understand that I have the right to terminate such care and services that I receive from the undersigned therapist at any time. 

My signature affirms that I have read and communicated the above information to my mental health service provider.  The information presented is understood and enables me to make an educated, voluntary consent to treatment. 

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”).

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.

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.

TELEMEDICINE CONSENT

Telemedicine services is the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telemedicine also involves the communication of my medical/mental information, both orally and visually, to health care practitioners. I agree to participate in a telemedicine evaluation/supervision. By signing this agreement, I authorize the electronic transmission of my medical information and/or videoconference session so that it can be viewed by a doctor and other persons involved in my medical or mental health care. I understand that as with any technology, telemedicine does have its limitations. There is no guarantee, therefore, that this telemedicine session will eliminate the need for me to see a specialist in person. I understand there are potential risks with this technology: (1) The video connection may not work or that it may stop working during the consultation. (2) The video picture or information transmitted may not be clear enough to be useful for the consultation. (3) I may be required to go to the location of the consulting physician if it is felt that the information obtained via telemedicine was not sufficient to make a diagnosis. I give my consent to be interviewed by the consulting health care provider. I also understand other individuals may be present to operate the video equipment and that they will take reasonable steps to maintain confidentiality of the information obtained. I authorize the release of any relevant medical information about me to the consulting health care provider, any staff the consulting healthcare provider supervises, third party payers and other health care providers who may need this information for continuing care purposes. Upon completion of virtual services, I authorize SpecialistsMAT, PSC representatives, to sign on behalf of the responsible adult where a responsible adult/parent/caregiver signature is required for insurance or other payor documentation. I hereby release SpecialistsMAT, PSC, its personnel and any other person participating in my care from any and all liability which may arise from the taking and authorized use of such videotapes, digital recording films and photographs. I have read this document and understand the risk and benefits of the telemedicine consultation and have had my questions regarding the procedure explained and I hereby consent to participate in a telemedicine visit under the conditions described in this document.

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.

Collection Policy:

·   If you have active insurance, you must provide that information to us at check-in, as well as provide a copy of our insurance card. 

·   You must pay the co-pay that is required by your insurance on every visit.  We are considered Specialists, so we will have to collect the Specialists Co-Pay amount.  **If you are unsure as to whether you have a co-pay responsibility, you can see our front desk for assistance or contact your insurance.

·   You must make a payment on every visit towards your current balance.  Patient balances are typically due to a yearly deductible or co-insurance that is the responsibility of the patient.  Some balances may be due to not collecting the required co-pay on previous visits.  See the front desk for a more detailed explanation.  **Most medical practices require a full balance be paid prior to being seen.  Our office policy is more flexible and patient, as a courtesy to you.  We require that our patients make consistent payments towards their balances in order to remain an active patient at the practice. We are open to discussing a payment amount that is reasonable and easier for you to pay.

·   If your insurance policy changes or you lose insurance coverage (inactive status): you must update this information with our check-in staff, so that they can discuss payment options with you.

o   Our Self/Private Pay charge for bi-weekly appointments is: $112.50.

o   Our Self/Private Pay charge for monthly appointments is: $225.00.

o   These charges cover the cost of the provider visit, counselor, and in office urine testing.  Our practice does send urine samples out for confirmation testing, so you may receive a separate bill from a Lab that processes the confirmation.  You must contact the number on their separate lab bill to discuss any balance due amounts or payment options.

·   We are OUT OF NETWORK with the following policies, therefore we cannot bill to these insurance plans and payment will be due at the time of service, by the patient.

o   Wellcare AMBetterHealth

o   INDIANA Medicaid (all Indiana insurance policies)

o   Caresource of Indiana

o   Deaconess OneCare

o   Anthem Pathway PPO/Marketplace Policy

PATIENT RIGHTS AND PRIVACY PRACTICE

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED ANDDISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

THIS NOTICE APPLIES TO ALL OF THE RECORDS OF YOUR CARE GENERATED BY THE PRACTICE.  EXAMPLES OF HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU:

Emergency Situations. In addition, we may disclose medical information about you to an Organization assisting in a disaster relief effort or in an emergency situation so that your family can be notified about your condition, status, and location.
Required By Law.

We will disclose medical information about you when required to do so by Federal, State, or Local law.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a Court or Administrative Order. 

Law Enforcement. We may release medical information if asked to do so by a Law Enforcement Official:

In response to a Court Order, Subpoena, Warrant, Summons or similar process;
Inmates. If you are an inmate of a Correctional Institution or under the custody of a Law Enforcement;

Official, we may release medical information about you to the Correctional Institution or Law;

Enforcement Official. 

Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. 

Right to Amend. If you feel that the medical information we have about you in your record is incorrect or incomplete, then you may ask us to amend the information.

To request restrictions, you must make your request in writing

COMPLAINTS:

If you believe your Privacy Rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact our Office Manager, who will direct you on how to file an office complaint. All complaints must be submitted in writing, and all complaints shall be investigated, without repercussion to you.

The Office Manager can be reached at this number: 502-212-0071

*You will not be penalized for filing a complaint.

IF YOU WOULD LIKE A FULL COPY OF YOUR PATIENT RIGHTS, PLEASE SEE THE FRONT DESK FOR A PRINTED COPY

Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time.

Office of State Ombudsman

209 St. Clair St

Frankfort, KY 40601

866-596-6283

kyombud@ky.gov

I {name201} am giving consent to receive service at SpecialistsMAT.

*SpecialistsMAT does not treat patients under the age of 18 years of age.

Thank you for completing your new patient paperwork.

Click on the SUBMIT BUTTON below.

Go to the Team Member at the front counter.