Intake Form

Buprenorphine Consent 

1. I understand that becoming a buprenorphine patient means that I am admitting to being dependent on opioids and am seeking maintenance treatment for my addiction. 
2. I understand that I cannot see multiple physicians for this type of treatment at the same time, or receive other buprenorphine containing prescriptions 
3. I understand that physicians who provide buprenorphine treatment at WBK Healthcare Services facility only treat for opiate addiction and not for Pain management. 
4. I understand that by becoming a buprenorphine patient I will be required to attend counseling services for at least 2 hours per month and I will be referred to outside counseling services in the surrounding area. 
5. I understand that each treating physician has access to the PDMP, OARRS & CSAPP systems which can track any other medication I am prescribed and fill at a pharmacy. 
6. I understand that while in treatment I am not allowed to be prescribed any opiates or benzodiazepine prescriptions without the consent of the treating physician. 
7. I understand that if I am suspected or caught or diverting my medication I will be automatically discharged and will be reported to other local facilities and law enforcement. 
8. I understand that my urines will be monitored by video surveillance and will be sent out to a laboratory so that my treating physician can get the most accurate results of my screening. 
9. I also submit to random medication counts for my entire treatment. 
10. I also understand that I will be given a baseline physical exam (vitals) and review a treatment plan with my physician during my initial visit. 
11. I acknowledge that if I am discharged for breaking any policies that I will not be refunded for any payments made. 

Initial Treatment Plan 

Goals 

1. Patient will have 4 weeks to eliminate all illicit drug use. 
2. Patient will have 4 weeks to sign up and complete monthly counseling requirement. 
3. Patient will take medication as prescribed. 
4. Patient will also begin to focus on building a positive support system. 
5. Patient will also work with physician on additional goals that will allow them to accelerate their success in treatment, 

Plan 

1. Physician will make sure that patients are following all policies and procedures. 
2. Physician will also refer patients to additional services as deemed necessary. 
3. Physician will determine how frequently patients should return for follow-up appointments. 
4. Physician will monitor PDMP, OARRS, and/or CSAPP before each patient visit

Confidentiality Statement 

You are hereby notified that the confidentiality of patients is protected by Federal and State laws. 

You cannot reveal the identity, whereabouts, or status of any patient in this program without his or her WRITTEN CONSENT. Attached you will find a copy of Federal regulations pertaining to confidentiality, and additional information in the Federal Regulations 42 C.F.R. Part 2 (June 9, 1987) and,45 C.F.R. § 164.520. 

I fully agree to comply with the laws of confidentiality regarding patients and records held by WBK Healthcare Services and that any breach of confidentiality pertaining to the aforementioned will result in legal action being taken against you. 

Consent to RELEASE Information 

I authorize my treating physician to release information to: 

Any Pharmacy that I (Patient) decide to fill my buprenorphine prescription at, also to any other physician that prescribes me any additional medication that can affect my current treatment for opioid dependence. I also give permission to release limited information (Nature of emergency) to my listed emergency contact (Emergencies only).In addition I give my permission to release information to those that I personally give legal consent to this includes outside agencies such as CYS/CPS and court appointed attorneys 

The specific information to be released is: 

( x ) Whether or not the patient is in treatment ( x ) Nature of emergency 

( x ) Diagnosis and prognosis ( x ) Medical records 

( x) Brief description of patient’s progress ( x ) Pharmaceutical Inquiries 

( x ) Nature of services provided ( x ) Patient Pharmacy 

( x ) Whether patient has relapsed 

I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR, Chapter I, Part 2 and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and cannot be disclosed without my written consent unless otherwise provided for in the regulations. 

I understand that I may revoke this consent verbally or in writing at any time except to the extent that action has been taken in reliance on it. If not previously requested, this consent will expire 6 Months after patient exits from treatment . 

Unless I have specifically requested in writing that the disclosure be made in a certain format, my treating physician reserves the right to disclose information permitted by this authorization in any manner deemed to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically. 

Federal law prohibits a person or organization to whom disclosure is made from making any further disclosure of this information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by 42 CFR, Chapter I, Part 2. 

I understand that I may contact the main office for answers to my questions about the privacy of my health information at 114 Werner St. Bridgeville PA 15017, or by telephone at (412) 314-1822.