Resource Center: Setting up a practice, Printable form/checklist

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Consent to Release of Information Under Title 42, Part 2, Code of Federal Regulations
Description: 
An example of the wording and structure necessary in a consent for release of information form.
Source: 
Substance Abuse and Mental Health Services Administration (SAMHSA)
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Consent Form for Buprenorphine Treatment During Pregnancy
Description: 
This consent form -- reproduced with permission from the Boston Medical Center -- can be used with your pregnant patients who want to continue taking buprenorphine during pregnancy.
Source: 
Boston Medical Center
4
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Buprenorphine: A Guide for Nurses
Description: 
This SAMHSA guideline provides information on buprenorphine treatment for nurses and other clinical support staff who assist with buprenorphine induction and maintenance.
Source: 
SAMHSA
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Commonly Used CPT Codes – Primary Care (PDF)
Description: 
PDF of Commonly Used CPT Codes in Primary Care
Source: 
Clinical Tools, Inc.
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Sample Consent Form

Description: 
This is a sample of a consent form that can be used when initiating buprenorphine treatment for a new patient.

BUPRENORPHINE MAINTENANCE TREATMENT

Sample #1 --Patient information and consent to treatment with buprenorphine

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CTI Referral Form for Substance Abuse Treatment

Description: 
Form3used for referral to substance abuse treatment or counseling.

This form is for use by a primary care physician to refer a patient for substance abuse treatment. It could also be used to refer the patient for counseling.

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Buprenorphine Inventory Form
Description: 
This log can be used to keep track of office inventories of buprenorphine medication.
Source: 
California Society of Addiction Medicine (CSAM)
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Telephone Screen for Buprenorphine
Description: 
This document provides a form for recording important information about prospective patients, including drug use history, treatment history, criminal history, health information, and more.
Source: 
Colleen LaBelle, RN/Boston Medical Center
5
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Nursing Follow-up Visit
Description: 
This form can be used by nurses to note the areas that should be covered during a follow-up visit for patients on buprenorphine treatment.
Source: 
Colleen LaBelle, RN/Boston Medical Center
4
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Intake Checklist
Description: 
This checklist provides a list of the forms that must be signed, the information that should be recorded for each patient (including current medications and allergies), and tests and labs that should be drawn during the intake assessment.
Source: 
Colleen LaBelle, RN/Boston Medical Center
4.333335
Your rating: None Average: 4.3 (3 votes)
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