Consent

Pharmacy Consent Form for Buprenorphine Treatment

Description: 
By signing this Appointed Pharmacy Consent Form, the patient authorizes a provider to disclose to the pharmacy that he or she is being treated for opioid dependence; the pharmacy is also authorized to contact the provider to discuss treatment.

Name/Practice Name: ____________________________
Address: _____________________________________________
Address: _____________________________________________
City, State, ZIP: ________________________________________
Phone: _______________________________________________
Fax: _________________________________________________

APPOINTED PHARMACY CONSENT

I, ______________________________________________[Patient Name- Print], do hereby:

(MD check all that apply)

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Consent to Release Confidential Information

Description: 
Consent to Release Confidential Information

Consent to Release Confidential Information
I ___________________________________ hereby authorize and request,
Name: ______________________________________

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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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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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Derechos de los pacientes: confidencialidad y consentimiento (Patient Rights: Confidentiality and Consent (en Español))

Description: 
This patient handout explains how consent and confidentiality are respected as a part of drug treatment.

Como un paciente que recibe tratamiento por un desorden del consumo de drogas, su
información personal y médica es protegida bajo la ley de confidencialidad de los Estados
Unidos. Esta ley declara que su médico no puede decir a nadie la razón por su tratamiento sin
el permiso de usted. Los médicos y programas del tratamiento que proveen tratamiento para la
adicción ni siquiera pueden decir que usted es un paciente.

Consentimiento del paciente

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Patient Handouts: 
Description: 
This patient consent form (in Word®) explains buprenorphine treatment and warns about the adverse effects of mixing buprenorphine with other medications. The section at the bottom is for the patient and a witness to sign and date, indicating that the patient understands and wishes to receive treatment.
Source: 
California Society of Addiction Medicine (CSAM)
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Physician stage in practice: 
Resource Type: 
Description: 
The California Society of Addiction Medicine (CSAM) website provides information and materials for buprenorphine treatment providers, including screening tools and sample consent and patient agreement forms, and provides links to other helpful resources.
Source: 
California Society of Addiction Medicine (CSAM)
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Description: 
Analyzes the misconceptions that arise from the Health Insurance Portability and Accountability Act and discusses when health care providers should use their professional judgment in deciding whether a disclosure is necessary.
Source: 
Journal of the American Medical Association (JAMA) 2005 Apr 13;293(14):1766-71.
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Description: 
This series of tables provides state-by-state information about minors' rights regarding providing consent for substance abuse treatment.
Source: 
Guttmacher Institute
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