Just became waivered

Description: 
Provider's Clinical Support System (PCSS-MAT) is a national training and mentoring project. Offerings include online training modules and webinars, resources, and a mentor program for providers of medication assisted treatment who are getting started or have less experience.
Source: 
PCSS/MAT
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Physician stage in practice: 

Transfer from Methadone Form

Description: 
This form provides a list of important considerations when determining whether a methadone patient is a candidate for transfer to buprenorphine treatment, including social, medical, and psychiatric history.

 

 Request Transfer from Methadone Maintenance to Office-Based Opioid Treatment 
Utilizing Buprenorphine 


Client Name: ______________________________
Date: ______________________________________
Admission Date: ___________________________
ID#: ________________________________________
DOB: _______________________________________

 

Transfer Criteria (please check the appropriate box and fill in as much information as possible):

[] On 30mg or less of Methadone.

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Description: 
This web page provides information for the patient on pronunciation, brand names, common uses, how to use, missed doses, precautions, side effects, drug interactions, proper storage, and more.
Source: 
Kaiser Permanente
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Description: 
This web page provides information for the patient on pronunciation, brand names, common uses, how to use, missed doses, precautions, side effects, drug interactions, proper storage, and more.
Source: 
Drugs.com
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Description: 
PCSS-MAT provides ongoing mentoring programs aimed at improving providers confidence in treating opioid use disorder. The PCSS-MAT program is designed to assist providers in incorporating the use of medications for prescription opioid addicted patients in their practices. The mentoring program is available, at no cost to providers. PCSS-MAT mentors are a national network of trained providers with expertise in medication-assisted treatment and skilled in clinical education. Mentors provide support by telephone, email, or in person if logistically possible. (From the website.)
Source: 
SAMHSA
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Physician stage in practice: 

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 provider to refer a patient for substance abuse treatment. It could also be used to refer the patient for counseling.

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Patient Rights: Confidentiality and Consent

Description: 
This is a patient handout to inform patients about their rights when undergoing office-based buprenorphine treatment.

Patient Rights: Confidentiality and Consent

As a patient getting treatment for a substance use disorder, your personal and medical
information is protected under United States confidentiality law. This law states that your provider
is not allowed to tell anyone the reason you are being treated, without your permission. Providers
and treatment programs that provide addiction treatment are not even allowed to tell anyone
whether or not you are a patient.

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Commonly Used Forms: 

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

Buprenorphine is an FDA approved medication for treatment of people with heroin or other opioid addiction. Buprenorphine can be used for detoxification or for maintenance therapy. Maintenance therapy can continue as long as medically necessary. There are other treatments for opiate addiction, including methadone, naltrexone, and some treatments without medications that include counseling, groups and meetings.

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