MAT Disclosures & Consents 1 of 6 Authorization & Disclosure ***YOUR INSURANCE MAY NOT PAY FOR ROUTINE SCREENING*** *** APPROPRIATE SCREENING DIAGNOSES MUST BE PROVIDED WHEN INDICATED*** Urine Drug Test I voluntarily consent to the collection and testing of my urine specimen (the Specimen ). I certify that the specimen consists of my own flesh and unadulterated urine. I certify the accuracy of the information I have provided Renew Addiction Treatment, including the information on Specimen bottle s label. I acknowledge that my provider will be ordering multiple Urine Drug Analysis. This is not only required for accurate treatment, but important to ensuring the best possible outcome. I acknowledge that this Urine Drug Analysis is a separate cost and will be billed to me separately. I hereby request that My Insurer make payment, weather to me or, on my behalf for the urine drug testing services ordered for me by my physician at RENEW Addiction Treatment. Medication!I acknowledge that my Renew Addiction Treatment physician has prescribed a medication to treat my addiction.i acknowledge that it is up to the sole discretion of RENEW addiction Treatment Centers and their physicians as to wether I will be prescribed any medication. I further understand and acknowledge that if a prescription is not written for me that no refunds for office visit fees will be given. Disclosure of Financial Interest I acknowledge I will receive laboratory services from Toxperts, LLC. I acknowledge that Renew Addiction Treatment Center and the owner of its managing firm, ADAPT Specialties, LLC, owns a direct interest in Toxperts, LLC. Effective Alternative Laboratories Quest Diagnostics Patient Care Center (Coal Run) Lab Corp, Inc (Coal Run) Pikeville Medical Center Out-Patient Center (Pikeville) I understand I have the option of using any one of the above alternative facilities, or any other facility of my choice. I understand Renew Addiction Treatment will not treat me any differently if I choose to use a laboratory other than the one which I will be automatically referred to. Print Name: Signature: Date of Birth: Date:
MAT Disclosures & Consents 2 of 6 Medical History and Consent for Treatment I Certify that the information contained herein and throughout this intake packet is accurate, complete and true. I authorize Renew Addiction Treatment and any associates, assistants and other health care providers it may deem necessary to treat my condition. I understand that no warranty or guarantee has beed made of a specific result or cure. I agree to actively participate in my care to maximize its effectiveness. Medication History Consent A medication history is a list of medicines that Renew Addiction Treatment, family physicians and other doctors have recently prescribed for patients. It is collected from a variety of sources, including a patient s pharmacy, KASPER, health plans, other health care providers. I give my consent for Renew Addiction Treatment to retrieve and review my medication history. I understand that this will become part of my medical record. Privacy Practices and Consent to Release Protected Health Information I acknowledge that I have had the opportunity to review Renew Addiction Treatment Notice of Privacy Practices, which is displayed for public inspection at its facility and on its website. This notice describes how my protected health information may be use and disclosed, and how I may access my health records. I authorize Renew Addiction Treatment to release my Protected Health Information (medical records) in accordance with its Notice of Privacy Practices. This includes, but not limited to, release to my referring physicians, primary care physician, and any physician(s) I may be referred to. I also authorize Renew Addiction Treatment to release any information required in obtaining procedure authorization or the processing of any insurance claims. I understand Renew Addiction Treatment will not release my Protected Health Information to any other party (including family) without my completing a written Patient Authorization for Use and Disclosure of Protected Health Information form available at its facility and on its website. Initial Here Financial Policy We are dedicated to providing the best possible care for you and we want you to completely understand our financial policies. 1. Payment is due at the time of service. We accept cash and credit cards. 2. Should I be extended a line of credit, I acknowledge that additional screening fees may apply. 3. I have been made aware of all fees, which are posted inside the lobby, on the premises and readily available for my inspection. I have read and understood the practice s financial policy and I agree to be bound by these terms. I also understand and agree that such terms may be amended by the practice from time to time. Initial Here
MAT Disclosures & Consents 3 of 6 Code of Conduct I will treat the staff and providers who work at Renew Addiction Treatment with courtesy and respect at all times. I understand that the practice has zero-tolerance policy regarding rude, vulgar, profane or harassing comments or actions to any practice member. This includes repeated telephone calls requesting or demanding medications or early appointments with any specific provider. Patients who exhibit patients who want to cooperate on their medical treatments. Missed Appointment Policy Please be aware that by making an appointment with our physicians that you are agreeing to abide by the billing policies of our service. There will be a $20.00 Fee, billed to you personally, if you do not provide 48 business hours notification of cancellation or reschedule. You must show up five minutes early for appointments (forty minutes early if you do not have all your paperwork filled out). *FEES MUST BE PAID ON DATE OF VISIT* Psychological Treatment Have you ever had psychiatric, psychological, social work evaluation or treatments for any problem, including you current pain? No Yes For what diagnosis were you treated? When? Please list your current or last therapist? Have you ever considered suicide? No Yes When? Have you ever planned suicide? No Yes When? Have you ever attempted suicide? No Yes When? History of sexual abuse during childhood? No Yes When? Patient Rights & HIV/AIDS Information Your safety and concerns are extremely important to us. We understand and realize that you have a choice when it comes to your treatment and we are excited you have chosen us. In an effort to ensure your care is top priority, we want you to know that you have certain rights with in this clinic. These Patient Rights are posted conspicuously in the lobby and on our website at www.renewtreatment.com. Our staff will also give you a copy of these rights upon your request. We also want you to be informed about the dangers of HIV/ AIDS and its impact on Substance abuse/use disorders. Copies of this information are provided in this packet. I Acknowledge I have been informed of my rights as a patient and to materials related to HIV/AIDS.
MAT Disclosures & Consents 4 of 6 Informed Consent I agree to comply with any pill counts and witnessed urine drug screens required of me. These will help document my progress in treatment. I also agree to protect and store the medicine properly. I will keep it safely away from children, household members, guests, and pets. If any unauthorized individual ingests the medicine, patient MUST call 911 or poisons control (1-800-222-1212) immediately. I have been informed that on the day I start buprenorphine, I should come to the office already in opiate withdrawal. The day before induction I will not use any opiate of any kind. If I am not having observable signs of withdrawal, my induction may be delayed or even rescheduled. I agree that I will not drive a motor vehicle or use power tools or other dangerous machinery during my stabilization phase (getting used to the effects the medicine has on me), making sure that I can tolerate taking it without becoming sleepy or clumsy. I will arrange transportation to and from my induction at RENEW Addiction Treatment Center. I agree to take Suboxone as prescribed at the dosage determined by my doctor, to not change the dose or frequency of Suboxone without discussion and agreement with my doctor, and to never allow anyone else to take medications prescribed for my use. I agree not to sell, share or give any of my medicine to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without recourse for appeal. My treatment spot would be forfeit to the next patient on the wait list. Lost prescriptions/tablets or stolen prescriptions/tablets are a serious issue and may result in discontinuation of buprenorphine therapy from this office. I agree that if my treatment team recommends that my home supply of medicine should be kept in the custody of a responsible member of my family or trusted third party, I will abide by such recommendations. I agree to report my history and my symptoms honestly to my treating physician and staff. I also agree to inform office staff of all other physicians and dentists I see; of all prescriptions and nonprescription drugs I am taking; of any alcohol or street drugs I have recently been using. If I develop any new medical problems or am prescribed any new medications, I will notify RENEW staff immediately! I want to be in recovery from addiction to all drugs, and I have been informed that any active addiction to other substances other than opiates must be treated by counseling and other methods. I have been informed Suboxone only treats opiate dependence. I further clarify that I have been informed of other treatment options including: A. medical withdrawal and drug-free treatment B. Naltrexone treatment alone C. Methadone treatment.
MAT Disclosures & Consents 5 of 6 I have been informed that Suboxone is itself a partial agonist opiate and can produce physical dependence similar to other opiates. I also understand that if an addict with opiates in their system takes Suboxone, they could experience immediate, acute, total, severe withdrawal. I have been informed that mixing buprenorphine with other medications, especially benzodiazepines (such as Valium, Klonopin, Ativan, Xanax, Librium) and/or other drugs of abuse including alcohol, can be dangerous. Accidental overdose, over-sedation, coma, and death are understood risks if I abuse any other substances while on Suboxone. I have been informed that buprenorphine treatment for opiate dependence is most effective when combined with drug abuse counseling, 12-step recovery work, or a recovery support group. During my treatment with Suboxone, I agree to seek additional counseling and to work on a program of recovery. I agree to notify the Clinic immediately in case I relapse to drug abuse. I know this can be lifethreatening and my appropriate treatment plan must be revised as soon as possible for my safety. The physician should be notified before a urine screen reveals it. Trust goes a LONG way in treatment relationships. I understand the goal of opiate dependent treatment is to learn to live without abuse of drugs. Suboxone therapy should continue as long as is individually necessary to avoid relapse to opiate abuse/dependence. WOMEN ONLY I affirm that I am NOT currently pregnant and I will NOT attempt to become pregnant while taking Suboxone. I agree to not have unprotected sex during treatment. If for any reason I become pregnant, I have been informed the clinic will almost certainly discontinue my buprenorphine regimen and refer me directly to a methadone clinic (maintenance treatment of choice for person s pregnant and opiate dependent). I have read and I understand these details about Suboxone treatment. I wish to be treated for my opiate addiction diagnosis with Suboxone. I very clearly understand that violation of any clinic rules either once or repeatedly can result in my being terminated from this treatment program. AUTHORIZATION I freely and voluntarily agree to accept this informed consent, treatment agreement, and Disclosures & Consents as outlined in the preceding pages. I authorize Renew Addiction Treatment to proceed as indicated in the above consent sections. Signed: Date:
MAT Disclosures & Consents 6 of 6 Authorization For Release of Information Patient Information: ( ) Patient Name (Print) Date of Birth Phone Number Last 4 digits of Social Security # You may release my information FROM: You May release my information TO: Clinic Provider Name Name (i.e. Attorney, Provider, self) Address City, State, Zip Address City, State, Zip ( ) ( ) ( ) ( ) Fax Phone Fax Phone Information to be released: The most recent 2 YEARS of pertinent information (Chart notes, lab reports, x-rays and special tests) All medical records Specific information (Please specify): Purpose for which information is being released (check one): Attorney Insurance Provider Personal Other (specify): Patient Authorization: I understand that my records may contain information regarding the diagnosis or treatment of HIV/AIDS, sexually transmitted diseases, drug and/or alcohol abuse, mental illness, or psychiatric treatment. I give my specific authorization for these records to be released. This authorization, unless expressly limited by me in writing, will extend to all aspects of treatment, including testing and.or treatment for sexually transmitted disease, AIDS, or HIV Infection, alcohol and/or drug abuse, and mental conditions. My Rights: I understand I do not have to sign this authorization in order to obtain health care benefits (treatment, payment or enrollment). I may revoke this authorization in writing. To view the process for revoking this authorization, please read the Privacy Notice to patients posted at the facility were your information is being released. I understand that once the health information I have authorized to be disclosed reaches the note recipient, that person or organization may re-disclose it, at which time it may no longer be protected under Privacy Laws. SIGNATURE DATE PATIENT, GUARDIAN*, OR AUTHORIZED REPRESENTATIVE * PLEASE PROVIDE DOCUMENTATION TO PROVE AUTHORITY TO SIGN ON BEHALF OF THE PATIENT. This authorization will expire on: Date Specific Event If no date/event is given, the authorization shall expire 90 DAYS form the date signed.