Southlake Psychiatry. Suboxone Contract

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1 Suboxone Contract Thank you for considering Southlake Psychiatry for your Suboxone treatment. Opiate Addiction is a serious condition for which you may find relief with Suboxone treatment. In order to increase your chance for successful treatment and due to the increased monitoring required by the DEA, we have found the following guidelines necessary for us to follow. Please read and sign the Suboxone contract, complete the opiate and other substance use questionnaire, complete the opiate use checklist, sign and date all areas requiring a signature and bring these to your initial interview. GENERAL 1. You must clearly understand, under no circumstances can you take your medication other than how it is prescribed. If the medication prescribed is not relieving your clinical symptoms, it is your responsibility to contact this practice and inform us, so we can instruct you on what you may do. If you do not adhere to this, you may be discharged from this practice or have your Suboxone dose reduced. 2. This practice will not prescribe any benzodiazepines to patients who are taking Suboxone. 3. If you lose your prescription, or for any reason your medication is misplaced, lost or even stolen, no substitute prescription will be provided. Understand that losing or misplacing a controlled prescription may have serious medical consequences, including withdrawal, even death. Please notify us if this occurs so we may assist you. Suspected misuse of Suboxone may result in being discharged from the practice. 4. All Suboxone patients will be using one pharmacy CVS, to fill their Suboxone prescriptions. You will need to provide us with the name and phone number of the CVS pharmacy you prefer. 5. All fees are due at the time of the visit with us, before seeing your medical provider. 6. All patients who are receiving prescribed Suboxone will be required to attend counseling with a licensed counselor. You are required to sign an Authorization to Disclose Information and provide the phone number of your counselor to allow unlimited communication between your medical provider here and your counselor. Please note HIPPA policy and procedures will apply. If you fail to cancel in time or fail to attend an appointment with your counselor, you may be discharged from this practice or have your Suboxone dose reduced. RANDOM URINE DRUG SCREENS 1. During the initial evaluation and at each successive follow up visit, patients who receive prescribed Suboxone will inform the medical provider of all medications or illicit drugs that have been taken over the past thirty days or between visits, whichever is longer. A form entitled Controlled Substances Check List will be provided for you to complete. Note, please take your time when completing this check list. If the drug screen identifies illicit drugs or prescribed medications that were not disclosed, you may be discharged from this practice or have your Suboxone dose reduced.

2 Suboxone Contract 2. You are required to submit to Random Drug Screening performed by LabCorp and/or Southlake Psychiatry. This will be done at the discretion of your medical provider. You are responsible for all fees associated with the Drug Screening. You are responsible for locating a LabCorp convenient for you, and for providing us the address and phone number of that LabCorp location. You will be notified by phone of the need to get the urine drug screen and will be required to present within four hours to your LabCorp location. If for some reason, you are unable to perform the urine drug screen in time, you must provide written reason why you were unable to do so and you may be discharged from this practice or have your Suboxone dose reduced. 3. Please understand, Suboxone will not be a medication of dependency and therefore Suboxone will replace taking any other opiates. Discussion about stopping Suboxone will be initiated at your first evaluation and with your first dose of this medication. Reduction of dosing will be performed in a manner to minimize the risk of withdrawal symptoms. If you have fears and reluctance regarding reduction of your Suboxone this matter must be discussed with your Counselor (see below for responsibilities regarding counseling). 4. If this practice is prescribing Suboxone and this medication is not identified through random drug screening you will be discharged from this practice immediately. OFFICE APPOINTMENTS WITH SOUTHLAKE PSYCHIATRY 1. If you need to cancel your appointment with us, it is our practice policy that you call 24 hours prior to your scheduled appointment. If you fail to cancel in time or fail to attend an appointment with your medical provider, you will be charged for the appointment, and you may be discharged from this practice or have your Suboxone dose reduced. 2. If you have a justifiable reason for cancelling within the 24 hour period or missing an appointment, you must provide us in writing the reason you were unable to your counselor or medical provider. If you were ill you must provide a written medical excuse from the medical provider you saw. Signing below indicates that you understand of this treatment contract and you agree to adhere to all the above requirements. Name Date of Birth Signature Date

3 Opiate and other Substance Use Questionnaire When was the very first day that you ever took an opiate? What was the reason? (circle one): Experimental, Recreational, Pain management (prescribed), pain management (not prescribed) What opiate did you first take? (circle one): Hydrocodone, Oxycodone, Heroin, Fentanyl, Methadone Other (describe): Which opiates have you used regularly, How many years have you taken opiates? Did you ever have a period of time when you were able to stop taking opiates? (circle one): Yes / No and What is the longest a period of abstinence you ve had? What route of administration did you prefer? (circle one): Oral, Injection, Inhalation In the space provided below please list and describe any other controlled substances you have used, including alcohol. Use of any controlled substances (prescribed or illicit) other than Suboxone such as Benzodiazepines, stimulants, alcohol, marijuana, and cocaine use is prohibited while receiving prescribed Suboxone. Please anticipate that any information listed here will be shared with your substance abuse counselor to aid your recovery. 1) Substance (Alcohol) Last used Amount Route of administration (oral) 2) Substance Last used Have you ever had a period of abstinence from this? (circle one) Yes/No How long?

4 Opiate and other Substance Use Questionnaire 3) Substance Last used 4) Substance Last used 5) Substance Last used 6) Substance Last used *Please fill out more copies of this page if you have additional substances to list. **Please note random drug screening will be required at the discretion of your medical provider, see Suboxone contract for details

5 Opiate and other Substance Use Questionnaire Important information you need to know and/or bring prior to your first, initial visit: Insurance Coverage: Insurance companies require certain criteria which must be met and maintained in order to cover your visits and your Suboxone. The criteria usually include the following and possibly other criteria. It is your responsibility to contact your insurance company and seek out this information. Please provide your Insurance information to the office prior to your visit so we may verify your Insurance, bring your Insurance card with you to your office visits. Please see our practice Financial Agreement for additional information. 1. The individual must be opiate dependent 2. The individual must receive Suboxone from a physician who has the DEA # specific to Suboxone prescribing 3. The individual must be involved in substance abuse counseling; this is also a requirement of this practice 4. The individual must abstain from any other opiate use Important information you need bring with you to your first appointment: 1. CVS (800) will be the only pharmacy utilized in dispensing Suboxone; write the phone number for the CVS convenient to you. 2. LabCorp (800) will be the only lab where urine drug screening will take place. Write the phone number and location of the LabCorp where you can present within 4 hours of being instructed to obtain a Random Drug Screen. Phone# Location 3. It is your responsibility to have a working cell phone so that we may contact you, and to update your phone number with us should it change. 4. At the time of initial evaluation please provide either your NC driver's license or approved NC identification. 5. You must inform us of any change in address. Signature: Date: Name DOB

6 Suboxone Contract Prevention of Suboxone induced withdrawal symptoms is the primary reason for the waiting period after stopping other opiates and before starting Suboxone. Starting Suboxone may cause opiate withdrawal if taken too soon after your last opiate use. Therefore it is imperative that you accurately report your last opiate use. Recommended wait time between last opiate use and starting Suboxone Dilaudid 12 to 24 hours Fentanyl 48 to 72 hours after patch removal Heroin 12 to 24 hours Hydrocodone 12 to 24 hours Methadone 72 to 96 hours Morphine 12 to 24 hours Oxycodone 48 to 72 hours Opiate used Date, amount, and last time used (circle all that apply) Dilaudid Fentanyl Heroin Hydrocodone Methadone Morphine Oxycodone Other Signature Date Name DOB

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