Program Responsibilities

Program Responsibilities

Review the following patient responsibilities (includes medication, financial, office and group setting responsibilities).,

I understand that medication alone is not sufficient treatment and I agree to participate in the recommended treatment of counseling which is an important part of this program. I am required to attend group sessions at least four times a month in order to meet the requirements of attending four hours of groups within a 28 day period; failure to do so will result in the inability to see the prescribing physician for my prescription. I have been advised that I cannot attend two groups within the same week as it would not be beneficial to my treatment by having a three week gap in services.

All patients in the Buprenorphine treatment program will follow these policies as written. Any deviation of this policy by the patient will place the patient in a non-compliant status. As a patient, if you have two areas of non-compliance within a two month or less period you will be discharged from the treatment program (example: 1 missed group and 1 failed urine test).

I understand that Core reserves the right to access the NC controlled substance data reports to ensure my compliance with this treatment program. Core will check Buprenorphine treatment program patient reports on a monthly basis or when deemed necessary. Patients who are found to be getting prescriptions that are prohibited will be discharged immediately.

I understand that all Buprenorphine patients are required to have a urine drug screening monthly. Once a test is requested patients are required to produce the test within two hours. Failure to produce the test within two hours or refusing to test will be considered a failed urinalysis which may result in discharge from the program.

I understand Core reserves the right to complete a urinalysis at a minimum of two weeks prior to my doctor appointment. If the test produces a second positive result in any category other than what I have been prescribed, I will be discharged from the Buprenorphine program. A positive drug screening for Benzodiazepines, Amphetamine/Methamphetamine, Opiates, Cocaine, or other illicit drugs will constitute a failed drug screening. I have been advised that I may have a urinalysis during my group sessions and if I do not have a urinalysis completed two weeks prior to my doctor’s appointment, I am required to complete a urine test prior to seeing my prescriber.

I understand that as a patient of the Buprenorphine treatment program I will be required to sign a letter of non-compliance if I produce a positive drug screening. This letter will become a permanent part of my medical record.

Medication Responsibilities

I understand that NO MEDICATION is kept on site including Suboxone, Subutex, or any other Narcotic.

I agree that group is a requirement of treatment and I must attend at least four groups within a 28 day period in order to receive my prescription. Any missed group sessions prior to my doctors’ appointment will result in me not being able to get medication until my next scheduled visit and once I meet all the treatment requirements to remain in compliance.

I agree that the medication I receive is my responsibility and that I will keep it in a safe and secure location. I agree that lost medication will not be replaced regardless of reason.

I agree to take my medication exactly as prescribed by the doctor and not to alter my medication schedule without first consulting the doctor.

It is a felony to be found trading or selling your prescription; prescription/medication counting maybe utilized during my treatment to ensure I am taking the medication exactly as prescribed. I agree not to sell, share or give away any of my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in discharge from treatment without recourse for appeal or reimbursement.

I agree not to obtain medications from any physicians, pharmacists, or other sources without informing my treatment physician. I understand that mixing Buprenorphine with other medications, especially benzodiazepines (such as: valium-(diazepam), Xanax-(alprazolam), Librium-(chlordiazepoxide), Ativan- (lorazepam), Klonopin, and/or any other drugs of abuse including alcohol can be dangerous. I also understand the number of deaths have been reported in persons mixing Buprenorphine with Benzodiazepines.

I understand that I may be discharged immediately if I test positive for any Benzodiazepine.

Financial Responsibilities

The following fees reflect the first-visit and monthly obligations fees for this program. Cost of Program: $360.00

I agree to pay all fees for this treatment program prior to being seen by the doctor. I understand I “WILL NOT BEEN SEEN” by the doctor if my program fees are not up to date.

All individual appointments require a 24-hour cancellation notice; if you do not cancel your appointment within 24 hours you will be charged a No-Show Fee of $75.00. I understand that if I fail to show up for the scheduled appointment visit, I will be required to pay the $75.00 No-Show fee prior to seeing the doctor.

I understand the Core Addiction Care does not accept insurance for this treatment program and all fees are cash and debit cards/credits only, Core does not accept checks for the addiction program. All fees are required to be paid in full on the date of service; failure to do can impact your ability to receive your prescription.

I further understand that if I am discharged from the program for any reason, I am not released from my financial obligations. I understand Core Addiction Care reserves the right to discharge me from the program if I violate any part of this agreement.

I am requesting that Core Addiction Care provide Buprenorphine treatment for my Opiod addiction. I freely and voluntarily agree to accept this treatment agreement. By signing below I affirm I have thoroughly read and understand this agreement. I agree to adhere to these policies and responsibilities.

Late, Missed, and Rescheduling Appointments:

All individual appointments require a 24-hour cancellation notice. If you do not cancel your appointment within 24 hours you understand there is a $75.00 no show fee. I understand that if I fail to show up or arrive too late for a scheduled visit, I will be required to pay the $75.00 no-show fee prior to seeing the doctor.

Group sessions require that attendees be present and ready to participate when the group session starts.

Upon start of the group session no new attendees will be permitted to enter.

Office and Group Setting Responsibilities

Group attendance is a requirement for treatment; group is a safe and trusting place to share difficulties you may be experiencing throughout your recovery. There will be no discussion of things that are discussed in group by other group members outside of group setting. This is a basic violation of group trust, against the law, and will NOT be tolerated. If you are found to be discussing other group member’s discussions or concerns outside of group you will be discharged from treatment.

I further understand that I may have to repeat the patient assessment process and will have to pay additional fees if I am discharged from the program and then readmitted to the program (if and when space is available).

I agree to conduct myself in a courteous manner while in the Core Addiction Care Facility.

I agree to not arrive intoxicated or under the influence of drugs. If I do, the staff will not see me and I will not be given any medication until my next scheduled appointment.

I agree to not deal, steal, or conduct any other illegal or disruptive activities in or around the vicinity of the doctor’s office.

I have read, understand, and have had the rules of Core Addiction Care’s Treatment Program explained to me and have been given a copy of these rules and treatment policy. My signature below affirms that I understand and have received a copy of this form.

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