Medication Assisted Treatment - Newport Integrated Behavioral Health Care

Medication Assisted Treatment

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Step 1 of 12

PATIENT INFORMATION

Last Name*

First Name*

Middle Initial

Nickname/AKA

Date of Birth*

MM slash DD slash YYYY

Social Security Number*

Gender*

Male

Female

Trans-gendered

Gender Neutral

Marital Status*

Married

Single

Divorced

Life Partner

Separated

Widowed

Other

Language other than English

Race (Optional)

Black-Non Hispanic

American Indian/ Alaskan Native

Hispanic

Asian/Pacific Islander

White-Non Hispanic

Multi racial

Other

Home Address*

Street City State Zip Code Country

Home Phone*

Work Phone

Other Phone

Email Address*

Employment Status

Active Duty Military

Employed Full-Time

Employed Part-Time

Homemaker

Not Employed

Student Full-Time

Student Part-Time

Child

Disabled

Retired

Self Employed

Other

Employer

Employer Phone

Highest Education Level

Legal: #of Arrests in Past 30 Days:

Current Medical Diagnosis:

PHYSICIAN REFERRAL INFORMATION

Primary Care Physician

Referring Physician

How did you hear about us?

Billboard

Employer

Friend

Magazine

Physician

Radio

Website

Yellow Pages

Health Fair Event

Mail

News

Family Member

Insurance

Television

Other

RESPONSIBLE PARTY (GUARANTOR) INFORMATION

Relationship to Patient

If SELF, skip to Emergency/Next of Kin. All other options must complete the information below.

Self

Spouse

Parent

Other

Last Name

First Name

Middle Initial

Date of Birth

MM slash DD slash YYYY

Social Security Number

Home Address

Street City State Zip Code Country

Home Phone

Work Phone

Other Phone

Employment Status

Active Duty Military

Employed Full-Time

Employed Part-Time

Homemaker

Not Employed

Student Full-Time

Student Part-Time

Child

Disabled

Retired

Self Employed

Other

Employer Phone

Insurance ID#

Group#

Upload Front + Back of Insurance Card

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Upload Photo ID Card

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EMERGENCY / NEXT OF KIN CONTACT INFORMATION

Last Name*

First Name*

Relationship with Patient

Home Address*

Street City State Zip Code

Home Phone

Work Phone

Other Phone

Patient Bill of Rights

Your rights include:

1. Right to a humane treatment or habilitation environment that affords reasonable protection from harm, exploitation, and coercion;

2. Right to be free from physical and verbal abuse;

3. Right to be free from the use of physical restraints and seclusion unless it is determined that there are no less restrictive methods of controlling behavior to reasonably insure the safety of the client and other persons:

4. Right to be informed about plan of treatment and to participate in the planning, as able;

5. Right to be promptly and fully informed of any changes in the plan of treatment;

6. Right to accept or refuse treatment, unless it is determined through established authorized legal processes that the client is un-able to care for himself or is dangerous to himself;

7. Right to be fully informed of the charges for treatment;

10. Right to converse privately, have convenient and reasonable access to the telephone and mails, and to see visitors, unless denial is necessary for treatment and the reasons are documented in the client's treatment plan; 11. Right to be informed of the program's complaint policy and procedures and the right to submit complaints without fear of discrimination or retaliation and to have them investigated by the program within a reasonable period of time;

12. Right to have access to their own client records and to obtain necessary copies when needed;

13. Right to receive a written notice of the address and telephone number of that state licensing authority, i.e. the department, which further explains the responsibilities of licensing the program and investigating client complaints which appear to violate licensing rules;

14. Right to obtain a copy of the program's most recent completed report of licensing inspection from the program upon written request. The program is not required to release a report until the program has had the opportunity to file a written plan of correction for the violations as provided for in these rules; and (b) Such policies and procedures shall also include provisions for clients and others to present complaints, either orally or in writing, and to have their complaints addressed and resolved as appropriate in a timely manner.

If you feel your rights have been violated, you may contact any of the agencies listed below:

1. The State of Georgia Department of Behavioral Health & Developmental Disabilities, office of External Affairs, (404) 657-5964 Or

2. Dept of Community Health Facility Regulations, (404) 657-5726 or 5728 and 1800-878- 6442-Address: 2 Peachtree St., Atlanta, GA 30303 Or

3. Georgia Advocacy Office in Atlanta, GA. (404) 885-1234, or 1800-537-2329 Or

4. Governor's Office of Disability Services Ombudsman, (404) 656-4261

Date

MM slash DD slash YYYY

Patient/Guardian or Parent of a Minor Signature

This consent form is to document that I give my permission and consent to Clinician and the other employees/contractors of Newport Integrated Belravioral Healthcare, Inc. to provide treatment to my child/grandchild or self. I understand that because of the counseling or therapy, I may experience emotional strain, feel worse during treatment, and make life changes that could be distressing.

I understand that this Clinician might or might not be providing an emergency service and I have been informed of whom to call in emergency or during weekend and evening hours. I understand that regular attendante will produce the maximum benefits but I or we am/are free to discontinue treatment at any time. If I decide to do so will notify the Clinician at least two weeks in advance so my st that effective planning for continued care could be implemented.

I understand that conversations with the Clinician will almost always be confidential with the exception of situations mentioned in client handout (Available at the Front Desk). I further understand that Clinician, by law, must report actual or suspected child or elder abuse to the appropriate authorities. In addition, the Clinician has a legai responsibility to protect anyone I may threaten with violence, harmful or dangerous actions (including those to myself) and may break confidentiality of communication if such a situation arises. I understand that the Clinician will make reasonably efforts to resolve these situations before breaking confidentiality.

I understand that I might be required to visit a licensed psychiatrist for an initial assessment and I agree with my Clinician scheduling and appointment for me. I also give consent to Newport Integrated Behavioral Healthcare, inc. to submit an appeal on my behalf, in case the authorization for services is denied by my Insurance Company. It is the client's responsibility to keep their Insurance current and if it lapses during treatment fees may be assessed on a sliding fee scale, or fee- for-service, and/or Insurance contracted rate. I know of no reason that I should not undertake this therapy and I agree to participate fully or voluntarily. I have read and understood the following forms and that I agree to abide by its terms during our professional relationship:

1. Introduction of our company and services
2. Client's Bill of Rights
3. Limits of Confidentiality
4. HIPAA Form
5. Client Rights Complaint Form
6. Choice of Provider
7. Consent to Treatment
8. Orientation of Advocacy
9. Orientation of Mental Health Advance Dir

10. Treatment Courses
11. Services that will be provided
12. Right to Ethical Treatment BY SIGNING THIS FORM I AM ATESTING TO THE FACT I AM LAWFULLY IN THE U.S.

Name of the client (printed)

Signature

Date

MM slash DD slash YYYY

Parent or Legal Guardian (printed)

Signature

Date

MM slash DD slash YYYY

USE THIS SPACE ONLY IF CLIENT/LEGAL GUARDIAN REFUSES THE TREATMENT

Consent

I voluntarily refuse the treatment of my child/grandchild and I am aware of legal and other implications related to my decision. I understand that the client needs to go through the new referral process if he or she is to re-enter the program

Parent/Legal Guardian/Client Signature

Signature

Date

MM slash DD slash YYYY

FINANCIAL ACKNOWLEDGEMENT

ASSIGNMENT OF BENEFITS: In consideration of the services provided at Newport Integrated Behavioral HC, I hereby assign and transfer to the Facility and other clinical providers all behavioral and medical provider benefits payable under my insurance policies or benefit plans. I hereby assign and transfer all related rights and remedies due under the insurance policies or benefit plans that I have identified or will identify in connection with all services rendered, including but not limited to all rights and remedies pursuant to applicable state, federal and ERISA regulation. I hereby assign and transfer all rights to the Newport and other medical providers applicable under ERISA, federal or state regulation to pursue any benefit denial, limitation of coverage or request for an administrative review of fiduciary duties involving administration of benefits by the U. S. Dept of Labor, the Department of Community Health or the Department of Insurance. I authorize and direct the insurance company to pay all such benefits to the Newport Integrated Behavioral Healthcare and appropriate clinical providers. I understand that assignment does not relieve me of any responsibility I may have for payment of charges not paid by the insurance company, unless otherwise provided by the

PRECERTIFICATION: I understand that my insurance policy may require compliance with a utilization review program to make certain that health care benefit funds are terms of an agreement between the insurance company and the Facility. expended when justified. I understand that it is the utilization review program's responsibility to review proposed elective admissions and anticipated courses of treatment. I understand that if the utilization review program determines that admission is necessary and appropriate and issues certification, the benefits of my health plan will be made available to me in accordance with the terms of my policy. However, if certification is denied, health care benefits may be withheld. I understand that precertification may be the responsibility of the patient or financially responsible party and his or her physician. I understand that Newport Integrated Behavioral Healthcare, Inc is willing to admit as requested by my psychiatrist. I also understand that I may be financially responsible for all residential charges incurred as a result of admission should the utilization review program refuse to certify that the admission is appropriate, or should the certification effort occur too late to be valid. I understand that to protect myself from unnecessary personal financial losses, I must provide insurance coverage at time of registration, review my obligations with my insurance company, utilization review program, and personal physician without delay.

ABOUT YOUR BILLING: Facility and Provider-Based Services- A bill will be received for the professional component of treatment. Although Newport Integrated Behavioral Healthcare may be a provider in an insurance network, the physician or professional service provider may or may not be a covered provider of service. If the care received is outpatient care, the insurance carrier will process the claim(s) on an outpatient basis. Outpatient services may require co-insurance, deductible and/or co-pay, depending on insurance policy benefits.

FINANCIAL RESPONSIBILITY: Payment in full is expected at the time services are received. Accounts more than 30 days past due will accrue percent a year. This interest does not apply to deductibles/copayments of Medicare/Medicaid or other govemmental programs. (Accounts under an agreed alternate interest at the rate of 8 payment contract will not be considered past due, provided the plan is accepted in writing.) Insured patients are required to pay identified co-pay, unsatisfied deductible, and estimated co-insurance prior to any elective services unless alternate arrangements are made. Uninsured patients are required to make payment in full prior to any elective services unless alternate arrangements are made. This provision does not apply, and payment will not be requested, prior to emergency screening and stabilizing treatment as required by federal law.

GOOD FAITH ESTIMATE: Under the law, NIBH need to give patients who do not have insurance or who are not using insurance an estimare of the bill for medical items and services. You have the right to receive a Good Faith Estimate in writing at least 1 business day before your scheduled appointment for the total expected cost of any non- emergency items or service. This includes related cost like medical tests, prescription drugs, equipment, and inpatient/hospital fees. In addition, you can also request a Good Faith Estimate before you schedule an appointment. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cmc.gov/nosurprise or call 1-800-985-3059

I authorize Newport Integrated Behavioral Healthcare, Inc., or any of its providers, agents, contractors or business associates, to contact me (by any telephone numbers, email addresses or other contact points provided by me or on my behalf) by the use of any automatic dialing system, by pre-recorded forms of voice/ messaging systems, by electronic mail owned or used by the guarantor/responsible party, by text messages, by telephone or by cell phone for reasons related to the services I received at Newport Integrated Behavioral Healthcare, Inc or payment for the services I received at Newport Integrated Behavioral Healthcare, Inc., including but not limited to, debt collection purposes. I further understand and acknowledge that my consent in receiving the aforementioned communications is not required nor is it a preceding condition to receiving health care services at Newport Integrated Behavioral Healthcare, Inc.

I do not agree with the above statement and do not wish to be contacted except for clinical issues. By signing below, I acknowledge and agree that I have read or had this form read to me and I understand and agree to its contents.

By signing below, I acknowledge and agree that I have read or had this form read to me and I understand and agree to its contents.

PATIENT / REPRESENTATIVE

Date

MM slash DD slash YYYY

RELATIONSHIP TO PATIENT

Interpreter Signature

Note: If phone interpretation used, record interpreter ID #

RECEIPT OF NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I acknowledge receipt of the Notice of Privacy Practices from Newport Integrated Behavioral Healthcare, Inc. The Notice of Privacy Practices provides information about how Newport Integrated Behavioral Healthcare, Inc and staff members may use and disclose my health information. I have been encouraged to read the notice in full.

I understand that the Notice of Privacy Practices is subject to change. If Newport Integrated Behavioral Healthcare, Inc changes its notice, I may obtain a copy of the revised Notice on site and/or at Newport's website (www.nibhinc.com).

PATIENT / REPRESENTATIVE

Date

MM slash DD slash YYYY

RELATIONSHIP TO PATIENT

Interpreter Signature

Note: If phone interpretation used, record interpreter ID #

CURRENT MEDICAL PROBLEMS
IF YOU ARE BEING TREATED FOR ANY OTHER ILLNESSES OR MEDICAL PROBLEMS BY ANOTHER PHYSICIAN, PLEASE DESCRIBE THE PROBLEMS & INDICATE THE NAME OF THE PHYSICIAN TREATING YOU. ILLNESS OR MEDICAL PROBLEMS PHYSICIANS TREATING YOU

medical lists

ILLNESS AND MEDICAL PROBLEMS

PHYSICIANS TREATING YOU

ILLNESS AND MEDICAL PROBLEMS

PLEASE MARK WITH A (X) ANY OF THE FOLLOWING ILLNESSES & MEDICAL PROBLEMS YOU HAVE OR HAVE HAD. ALSO INDICATE THE YEAR WHEN EACH STARTED. IF YOU ARE NOT CERTAIN WHEN THE ILLNESS STARTED, WRITE DOWN AN APPROXIMATE YEAR.

ILLNESS

JAUNDICE

HIGH BLOOD PRESSURE

MIGRAINE HEADACHES

HEADACHES

HEAD INJURY

HEART ATTACK

HIGH CHOLESTEROL

LIVER TROUBLE

GALLBLADDER PROBLEMS

HERNIA

STROKE

SEIZURE

POOR CIRCULATION

HEART MURMUR

BLEEDING TENDENCY

HEMORRHOIDS

GLAUCOMA

KIDNEY DISEASE

ANEMIA

BLADDER DISEASE

FAMILY HISTORY

PLEASE GIVE THE FOLLOWING INFORMATION ABOUT YOUR IMMEDIATE FAMILY:

AGE AT DEATH

STATE OF HEALTH OR CAUSE OF DEATH

ILLNESS

HEART DISEASE

HIGH BLOOD PRESSURE

CANCER

DIABETES

BLOOD DISEASE

EPILEPSY

RHEUMATOID ARTHRITIS

GOUT

GLAUCOMA

TUBERCULOSIS

Specify Whom

MEN ONLY ANY PROBLEMS WITH THE FOLLOWING

HERNIA

Yes

PAIN IN TESTICLES

Yes

SEXUAL DIFFIC

Yes

DISCHARGE FROM PENIS

Yes

SEXUALLY TRANSMITTED DISEASE

Yes

WOMEN ONLY - ANY PROBLEMS WITH THE FOLLOWING

Vaginal Itching/Burning

Vaginal Discharge

Problems with Menstrual Periods

First Menstrual Period

Date of Last Menstrual Period

Date of Last Pap Smear

Method of Contraception

Sexually Transmitted Disease

Sexual Difficulties

Number of Pregnancies

Number of Miscarriages/Abortions

Number of Live Births

Problems with Pregnancies

Lumps in Breast

Discharge from Nipple(s)

Date of Last Mammogram

DID YOU MISS MORE THAN (10) DAYS OF YOUR USUAL ACTIVITY LAST YEAR DUE TO ILLNESS OR INJURY? IF YES, PLEASE EXPLAIN:

PATIENT SIGNATURE

Date

MM slash DD slash YYYY

Arrive early to complete paperwork.
Bring all pill bottles.
Bring valid photo ID. Bring insurance card if insured.
Bring a driver.
Lab charges at NIBH will be billed to you or to your insurance. Bring proof of insurance if you are insured.
Must be in withdrawal to insure treatment is started the first day.
No Methadone for at least 2 days. Methadone dose for prior 7 days must be less than 31mg/day.
No narcotics for at least 12 hours and preferably 24 hours.
Plan to be drug tested for alcohol, marijuana, and other drugs.
First appointment will last up to 3 hours.
Bring proof of unemployment if uninsured.

Our treatment panel is restricted to a limited number of pre-qualified patients who are serious about overcoming opiate addiction. Privately insured patients must provide a current insurance card to confirm coverage. Uninsured patients must meet State-Funded Admission Criteria.

TO GET STARTED

Read the entire packet.
Complete

- Intake Questionnaire (2 pages)

- Consent for Release of Information

- Insurance Information form (if insured)

- Suboxone Materials Confirmation

STARTING THE PROGRAM

Schedule 1st visit with Dr. John L Moseri, MD for an Diagnostic Assessment.
A Urine Drug Screen will be performed.
A Counseling Assessment and Treatment Plan will be performed.
A Nursing Assessment will be performed.
Next you will be scheduled for 2 follow-up visits over the next 2-3 days.
You will be assigned a Counselor and a Group Schedule will be provided.
Allow for 3-hours for the 1st Visit.

Please read this information carefully. Suboxone (buprenorphine + naloxone) is an FDA approved medication for treatment of people with opiate (narcotic) dependence. It can be used for detoxification or for maintenance therapy when prescribed by qualified physicians. Suboxone itself is a weak opiate and reverses actions of other opiates! It can cause a withdrawal reaction from standard narcotics or Methadone while at the same time having a mild narcotic pain relieving effect from the Suboxone.

The use of Suboxone can result in physical dependence of the buprenorphine, but withdrawal is much milder and slower than with heroin or Methadone. If Suboxone is suddenly discontinued, patients will have only mild symptoms such as muscle aches, stomach cramps, or diarrhea lasting several days. To minimize the possibility of opiate withdrawal, Suboxone may be discontinued gradually, usually over several weeks or more.

Because of its narcotic-reversing effect, if you are dependent on opiates, you should be in as much withdrawal as possible when you take the first dose of Suboxone. You must be off Methadone for at least 24 hours or off of other narcotics for at least 12 hours and showing signs of withdrawal before starting Suboxone. If you are not in withdrawal at the time of your first visit, you may not be given Suboxone, as it can cause severe opiate withdrawal while you are still experiencing the effect of other narcotics. You will be given the first dose in our clinic and you must return to the office after two hours. After that, you will be given further instructions and a prescription for Suboxone that can be filled at the pharmacy of your choice.

Some patients find that it takes several days to get used to the transition to Suboxone from the opiate they had been using. After stabilized on Suboxone, other opiates will have virtually no effect. Attempts to override the Suboxone by taking more opiates could result in an opiate overdose. Do not take any other medication without discussing it with you physician first. Combining Suboxone with alcohol or some other medications may also be hazardous. The combination of Suboxone with mediation such as Valium, Librium, Ativan, or Xanax has resulted in deaths.

The form of Suboxone given in this program is a combination of buprenorphine with a short- acting opiate blocker, naloxone. If the Suboxone tablet was dissolved and injected by someone taking heroin or another strong opiate it would cause severe opiate withdrawal.

Suboxone tablets must be held under the tongue until completely dissolved. It is then absorbed from the tissue under the tongue over the next 30-120 minutes. If swallowed, Suboxone is not well absorbed from the stomach and the desired benefit will not be experienced.

We do not prescribe, under any circumstances, narcotics, Methadone, or sedatives for patients desiring maintenance or detoxification from narcotics. All Suboxone will be supplied!

SUBOXONE TREATMENT MAINTENANCE

Suboxone treatment may be discontinued for several reasons:

•Suboxone controls withdrawal symptoms and is an excellent maintenance treatment for many patients. If you are unable to stop your heroin abuse, or if you continue to feel like using narcotics, even at the top doses of Suboxone, the doctor will discontinue treatment with Suboxone and you will be required to seek help elsewhere.

• There are certain rules and patient agreements that are part of Suboxone treatment. All patients are required to read and acknowledge these agreements by signature upon admission to the treatment panel. If you do not abide by these agreements you may be discharged from the Suboxone treatment program.

• Prompt payment of office fees is part of this program. If your account does not remain current as agreed, appointments cannot be scheduled. If appointments cannot be kept as agreed, your status as an active patient will be canceled - no exceptions.

Obviously, in the rare case of an allergic reaction to medication, Suboxone must be discontinued.

• Dangerous or inappropriate behavior that is disruptive to our clinic or to other patients will result in your discharge from the Suboxone treatment. This includes patients who come to the clinic intoxicated or on other narcotics, Valium, barbiturates or Xanax like medications.

• In the case of dangerous behavior there will be no two week taper. You will be summarily discharged and asked not to return to the facility.

Patient Treatment Contract

Name

Date

MM slash DD slash YYYY

As a participant in Suboxone treatment at Newport Integrated Behavioral Healthcare, Inc, I freely and voluntarily agree to the following contract rules:

1. I agree to keep and be on time for all scheduled appointments.

2. I agree to adhere with the payment policy outlined by this office, applicable to fee-for-service or insured patients. 3. I agree to conduct myself in a courteous manner in the office. I agree not to sell, share, or give away any of my medication. I understand that failure to adhere to this core principle would

result in my treatment being terminated without any recourse for appeal.

4. I agree that prescriptions or medications will only be given or administered at scheduled office appointments. A missed office visit will result in my not being able to receive medication until the next scheduled appointment.

5. I agree the medication I receive is my responsibility and I agree to keep it in a safe place. I understand that lost medication will not be replaced regardless of how it was misplaced.

6. I agree not to receive Suboxone or any other opioid drug from any other physician without

telling your treatment provider at Newport Integrated Behavioral Healthcare, Inc.

7. I understand that Suboxone has narcotic analgesic properties and can cause sedation. Additionally, I understand that mixing with other sedating agents such as Benzodiazepines such as Ativan, Valium, Klonopin, and Librium can be especially dangerous and in some cases fatalities have occurred.

8. I understand that replacement therapy alone is not sufficient to treat a dependency issue and I agree to participate in SA IOP Services (Individual Outpatient Services, Group Outpatient Services, Nursing Assessment, Medication Administration, ADSS, Assessment & Service Plan, Psychiatric Services, Peer Support Services, and/or Family Outpatient Services) as discussed and

agreed upon by my provider and specified in my treatment plan. 9. I agree to abstain from all other illicit drug use including alcohol.

10. I agree to random drug screens and alcohol levels. Providing false samples will lead to termination from program.

11. I agree to random medication call-backs.

12. I agree that violations of any of the above will be grounds for termination of treatment.

Patient Signature

Date

MM slash DD slash YYYY

INTAKE QUESTIONNAIRE FOR PROSPECTIVE SUBOXONE PATIENT

Name*

Birthdate*

MM slash DD slash YYYY

Home Phone

Time Available

Cell Phone

Time Available

PLEASE ANSWER THE FOLLOWING QUESTIONS WHICH WILL HELP US DESIGN YOUR PLAN OF TREATMENT

1. Why are you interested in Suboxone treatment?

2. Have you been previously treated with Suboxone?

Yes

When was your last treatment?

How long were you treated?

3. Is there any problem that makes it difficult for you to give routine urine specimens?

Yes

4. List all past drug or present drug and/or alcohol treatments, locations, and dates:

5. What caused you to start on opiates originally?

6. Are these reasons listed in #5 above still a problem now?

7. What coping methods have you developed to deal with triggers to relapse?

8. What kinds of help are you currently receiving, or do you need, from a counselor or psychiatrist?

9. What benefit do you expect from Suboxone?

10. Is anyone in your home actively addicted to drugs or alcohol?

Yes

Who?

What substance?

11. What are the major sources of stress in your life?

12. What are your major strengths to deal with the stress in your life?

13. Who will provide for your medical care during this time?

14. What other past and present medical problems do you have? Please list:

15. The safety of your Suboxone medication or prescription is your responsibility. Requests for replacement Suboxone will not be honored without an appointment. Do you understand that following the loss or theft of your prescription, it is at the discretion of our physician to determine whether you will be allowed to continue in this program?

Yes

I have completed this form truthfully and to the best of my ability.

Signature

Date

MM slash DD slash YYYY

SUBOXONE INFORMATION FOR PATIENTS

The Drug Addiction Treatment Act of 2000 made it legal to prescribe a narcotic for treatment of addiction. A heroin addicted patient may receive opioid medication for detox or maintenance in a regular office setting, rather than a Methadone treatment program. Suboxone is the only allowed medication.

The restrictions of this law include requirements that the physician have training in opioid addiction treatment, be registered with the Secretary of Health and Human Services and be certified by the Drug Enforcement Administration to prescribe scheduled drugs.

Suboxone is a long acting opioid medication which binds for a long time to the narcotic receptor. Suboxone is taken sublingually (dissolved under the tongue) because it is not absorbed well by swallowing. This sublingual tablet also contains a small amount of naloxone (Narcan) which is a narcotic antagonist, or blocking/reversing agent, which will cause withdrawal if injected.

Suboxone has a "ceiling" which makes it safer in case of accidental overdose. In large doses Suboxone does not suppress breathing to the point of death in the same way that heroin and Methadone. If a child swallowed a bottle of Suboxone tablets (remember they are not absorbed well by swallowing) it would probably not be lethal. A single dose of Methadone, however, could be lethal to a child. These are some of the unusual qualities of this medication which make it safer to use outside of the strict confines of a Methadone clinic. After stabilization, most patients are able to self manage Suboxone for up to four weeks at a time.

Suboxone is not equivalent in maintenance strength to Methadone. In order to even try Suboxone without going into major withdrawal, a Methadone-maintained patient would have to taper down to a dose of 30 mg. of Methadone or lower.

So remember the following tips. If you are offered Suboxone by a "friend" and you are taking other opiates, the Suboxone will push the other opioids off the receptor site and you may go into withdrawal and become very sick. If you dissolve and inject the Suboxone- naloxone sublingual tablet, it may induce severe withdrawal because of the naloxone, which is an antagonist and reverses narcotics effect when injected. If you wish to transfer to Suboxone from Methadone, your dose has to be at or below 30 mg.

There have been deaths reported when Suboxone is combined with benzodiazepines. (This family of drugs includes Klonopin, Ativan, Hlcion, Valium, Xanax, Librium, etc.) If you are taking any of these drugs, either by prescription or on your own, Suboxone is not a good treatment for you and should not be taken.

SUBOXONE MATERIALS CONFIRMATION

DOCUMENT*

Check all items that you have completed on this form.

Suboxone New Patient Introduction

Suboxone Information for Patients Suboxone Patient Responsibilities

Patient Contract Suboxone Treatment Financial Policies

Follow up Appointment Protocol

Informed Consent

Suboxone Maintenance Treatment

Release of Information Consent (COMPLETE THIS FORM)

Intake Questionnare 2 pages (COMPLETE THIS FORM)

Suboxone Materials Confirmation (COMPLETE THIS FORM)

Insurance Information (COMPLETE THIS FORM)

Consent

My signature below and initials by the name of each individually listed document, certifies that I fully understand and agree to the contents of each document.

Signature

Printed name

Date

MM slash DD slash YYYY

SUBOXONE PATIENT RESPONSIBILITIES

Initial each statement below

I agree to store medication properly.*

I agree to store medication properly. Medication may be harmful to children, household members, guests, and pets. The pills should be stored in a safe place, out of the reach of children. If anyone besides the patients ingests the medication, the patient must call the Poison Control Center or 911 immediately.*

I agree to take the medication only as prescribed. The indicated dose should be taken daily, and the patient must not adjust the dose on his/her own.*

I agree to comply with the required pill counts and urine tests. Urine testing is a mandatory part of office maintenance. The patient must be prepared to give a urine sample for testing at each clinic visit and to show the medication bottle for a pill count, including reserve medication. If you cannot give a urine sample you will forfeit your appointment.*

I agree to make and prepay (if uninsured) for another appointment in case of a lost or stolen medication.*

I agree to notify the clinic in case of relapse to drug abuse. Relapse to opiate drug abuse can result in being removed from the Suboxone program. The physician should be informed of narcotic use before it is revealed by random urine testing.*

I agree to the guidelines of office operations.*

I understand the procedure for making appointments and paying for missed appointments and late cancellation fees.*

I have the phone number of this clinic and I understand the office hours.*

I understand that no medications will be prescribed by phone or on weekends. I understand that I am required to abide by these restraints in order to remain on the Suboxone treatment panel of this facility.*

I understand that I am required to abide by these restraints in order to remain on the Suboxone treatment panel of this facility.*

I understand that this treatment program does not provide medical or surgical care outside the scope of routine Suboxone maintenance.*

Prepayment is required prior to the first visit. This applies to ONLY Fee- For-Service.

We accept credit card, debit card, money order, or cash. No checks

FIRST VISITS: The cost for the initial Suboxone induction treatment is $350. This includes 3 visits within 3-5 days and your first dose of medication. In addition, insured patients will be expected to pay the required copay at each visit. There is a $50 cancellation fee (less than 24 hours notice).

FOLLOW UP VISITS: The cost for follow up appointments is $125. Follow up appointments are scheduled every 2-4 weeks. Insured patients will be expected to pay the required copay at each visit. Fee-For-Service will be required to participate in Individual Counseling twice a month for $60 per session. There is an $50 cancellation fee (less than 24 hours notice).

Urine drug screening will be required at every visit. The cost of drug screening is $30.

Payment for all prior visits must remain current in order to retain your reservation on the panel. Your reservation on our limited panel is secured with a paid up account. At the conclusion of your visit you will be asked to reserve your next visit. Uninsured patients will have to meet State Admission Criteria. We do not wish you to undergo sudden withdrawal from Suboxone. This will be the result if you fail to reserve and keep your appointments. Office fees include the cost of Suboxone management and drug testing and do not include treating any other medical or psychological problems or any other laboratory testing.

Follow up appointments will be at least monthly.

The visits are focused on evaluating compliance and the possibility of relapse. They may include:

Pill counts
Urine testing for drug abuse
An interim history of any new medical problems or social stressors
Prescription of medication
No refills of Suboxone will be made for any reason except during an office visit.
Appointments do not include evaluation or care for other problems

Dangerous behavior, relapse and relapse prevention.

The following behavior "red flags" will be addressed with the patient as soon as they are noticed:

Missing appointments
Running out of medication too soon
Taking medication off schedule
Use of any opiates/narcotics
Refusing urine testing
Neglecting to mention new medication or outside treatment
Agitated behavior
Frequent or urgent inappropriate phone calls
Outbursts of anger
Lost or stolen medication
Non payment of visit bills as agreed, missed appointments or cancellations within 24 hours of your appointment
Treatment may be discontinued if these behaviors occur

PATIENT INFORMATION

PHYSICIAN REFERRAL INFORMATION

RESPONSIBLE PARTY (GUARANTOR) INFORMATION

EMERGENCY / NEXT OF KIN CONTACT INFORMATION

Patient Bill of Rights

USE THIS SPACE ONLY IF CLIENT/LEGAL GUARDIAN REFUSES THE TREATMENT

FINANCIAL ACKNOWLEDGEMENT

RECEIPT OF NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

CURRENT MEDICAL PROBLEMS

ILLNESS AND MEDICAL PROBLEMS

FAMILY HISTORY

MEN ONLY ANY PROBLEMS WITH THE FOLLOWING

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STARTING THE PROGRAM

Patient Treatment Contract

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PLEASE ANSWER THE FOLLOWING QUESTIONS WHICH WILL HELP US DESIGN YOUR PLAN OF TREATMENT

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