Initial patient contact

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)

field_vote: 
Commonly Used Forms: 
Resource Type: 

Consent to Release Confidential Information

Description: 
Consent to Release Confidential Information

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

field_vote: 

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.

field_vote: 
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.

field_vote: 
Resource Type: 
Commonly Used Forms: 
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)
field_vote: 
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)
field_vote: 
Description: 
This patient questionnaire from the California Society of Addiction Medicine (CSAM) is useful when beginning a new patient on buprenorphine maintenance treatment.
Source: 
California Society of Addiction Medicine (CSAM)
field_vote: 
Resource Type: 
Commonly Used Forms: 
Tags: 
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
field_vote: 
Resource Type: 
Commonly Used Forms: 
Physician stage in practice: 
Description: 
This flow chart for buprenorphine treatment displays the steps to patient recovery, from initial patient contact or referral, through intake process, induction, day #2, stabilization, maintenance, and tapering.
Source: 
Colleen LaBelle, RN/Boston Medical Center
field_vote: 
Physician stage in practice: 

Pages

Subscribe to Initial patient contact