Overall, to this day, the risks and benefits of marijuana is still not fully understood. Some mixture of medications may cause or lead to further harm or consequences. Thus, before undergoing treatment using marijuana, one must consult with his/her physician.
I am being evaluated for a physician’s recommendation for the use of medical marijuana. The physician will make this recommendation based, in part, on the medical information I have provided. I have not misrepresented my medical condition in order to obtain this recommendation and it is my intent to use marijuana only as needed for the treatment of my medical condition, not for recreational or non- medical purposes. I understand that it is my responsibility to be informed regarding state and federal laws regarding the possession, use, sale/purchase and or distribution of marijuana. I have been informed of and understand the following:
A qualified physician may not delegate the responsibility of obtaining written informed consent to another person. The qualified patient o r the patient’s parent or legal guardian if the patient is a minor must initial each section of this consent form to indicate that the physician explained the information and, along with the qualified physician, must sign and date the informed consent form.
Benefits: Most of the benefits of medical marijuana are based on the positive experiences of patients. Evidence from research suggests that marijuana may be an effective treatment for chronic pain, nerve pain, and muscle spasms. Marijuana can reduce nausea and vomiting (Especially in patients receiving cancer chemotherapy), improve sleep and can increase appetite.
Risks and pertinent medicolegal acknowledgements:
1. The federal government has classified marijuana as a Schedule I controlled substance. Schedule I substances are defined, in part, as having (1) high potential for abuse; (2) no currently accepted medical use in treatment in the United States; and (3) a lack of accepted safety for use under medical supervision. Federal law prohibits the manufacture, distribution and possession of marijuana even in states, such as Pennsylvania, which have modified their state laws to treat marijuana as medicine.
2.Marijuana has not been approved by the Food and Drug Administration for marketing as a drug. Therefore the “manufacture” of marijuana for medical use is not subject to any standards, quality control, or other oversight. Marijuana may contain unknown quantities of active ingredients (i.e., Can vary in potency), impurities, contaminants, and substances in addition to THC, which is the primary psychoactive chemical component of marijuana.
3.The use of marijuana can affect coordination, motor skills and cognition, i.e., the ability to think, judge and reason. While using marijuana, I should not drive, operate heavy machinery or engage in any activities that require me to be alert and/or respond quickly. While using medical marijuana, I should not drive, operate heavy machinery or engage in any activities that require me to be alert and/or respond quickly and I should not participate in activities that may be dangerous to myself or others. I understand that if I drive while under the influence of marijuana I can be arrested for “driving under the influence.”
4.Potential side effects from the use of marijuana include, but are not limited to, the following: dizziness, anxiety, confusion, sedation, low blood pressure, impairment of short term memory, euphoria, difficulty in completing complex tasks, suppression of the body’s immune system, inability to concentrate, impaired motor skills, paranoia, psychotic symptoms, general apathy, depression and or restlessness. Medical marijuana may affect the production of sex hormones. Marijuana may exacerbate schizophrenia in persons predisposed to that disorder. In addition, the use of medical marijuana may cause me to talk or eat in excess, alter my perception of time and space and impair my judgement. Many medical authorities claim that use of cannabis, especially by persons younger than 25 can result in long term problems with attention, memory, learning, a tendency to drug abuse and schizophrenia. Dr. Ferraro recommends cannabis use only for the relief of serious symptoms, and not for habitual use.
5. I understand that using marijuana while under the influence of alcohol is not recommended. Additional side effects may become present when using both alcohol and marijuana. Cannabis should be treated as an open container of alcohol. It should not be within reach in the car and should not be extinguished in the vehicles ash tray.
6.I agree to contact ICTMG Medical office if I experience any of the side effects listed above, or if I become depressed or psychotic, have suicidal thoughts, or experience crying spells. I will also contact ICTMG Office if I experience respiratory problems, changes in my normal sleeping patterns, extreme fatigue, increased irritability, or begin to withdraw from my family and or friends.
7. Smoking marijuana may cause respiratory problems and harm, including bronchitis, emphysema and laryngitis. In the opinion of many researchers, marijuana smoke contains known carcinogens (chemicals that can cause cancer) and smoking marijuana may increase the risk of respiratory diseases and cancer in the lung, mouth and tongue. In addition, marijuana smoke contains harmful chemicals known as tars. If I begin to experience respiratory problems when using marijuana, I will stop using it and report my symptoms to a physician.
8.The risks, benefits and drug interactions of marijuana are not fully understood. If I am taking medications or undergoing treatment for any medical condition, I understand that I should consult with my treating physician(s) before using marijuana and that I should not discontinue any medication or treatment previously prescribed unless advised to do so by the treating physician(s). Numerous drugs are known to interact with marijuana and not all drug interactions are known. Some mixtures of medications can lead to serious and even fatal consequences. I agree to discuss medical marijuana treatment with all of my treating physicians to decrease risk of these consequences.
9. Individuals may develop a tolerance to, and /or dependence on marijuana. I understand that if I require increasingly higher doses to achieve the same benefit or if I think that I may be developing a dependency on marijuana, I should contact ICTMG Office.
10.Signs of withdrawal can include: Feelings of depression, sadness, irritability, insomnia, restlessness, agitation, loss of appetite, trouble concentrating, sleep disturbances and unusual tiredness.
11.Symptoms of marijuana overdose include, but are not limited to, nausea, vomiting, hacking cough, disturbances in heart rhythms, numbness in hands, feet, arms or legs, anxiety attacks and incapacitation. If I experience these symptoms, I agree to contact ICTMG Office immediately or go to the nearest emergency room.
12. Marijuana may increase the risk of bleeding, low blood pressure, elevated blood sugar, liver enzymes and other bodily systems when taken with herbs and supplements. I agree to contact ICTMG Office immediately or go the nearest emergency room if these symptoms occur.
13. I understand that medical marijuana may have serious risks and may cause low birthweight or other abnormalities in babies. I will advise ICTMG Office if I become pregnant, try to get pregnant or will be breastfeeding.
14. I have had the opportunity to discuss these matters with ICTMG Physician and to ask questions regarding anything I may not understand or that I believe needed to be clarified. I acknowledge that ICTMG Physician has informed me of the nature of a recommended treatment, including but not limited to, any recommendation regarding medical marijuana. ICTMG Physician has also informed me of the risks, complications and expected benefits of any recommended treatment, including its likelihood of success and failure. I acknowledge that ICTMG Physician informed me of any alternatives to the recommended treatment, including the alternative of no treatment, and the risks and benefits.
15. Quantity, specifications of treatment will be determined with the expert opinions of pharmacy practitioners, that are specifically trained in medical marijuana dosing and administration at your local dispensary. If there are any adverse effects I will stop the medication and notify ICTMG Physician immedietly.
16. When under the influence and/or in possession of cannabis in public, a copy of your recommendation/certification should be on your person at all times.
17. Patients giving any dishonest or untruthful information will be discharged.
18. I agree to not distribute my marijuana to any other person, for personal use or for sale. I am aware that redistribution of any marijuana for sale is an illegal activity.
19. I am aware that using marijuana is associated with psychosis in persons who are still undergoing neurodevelopment (brain growth). Therefore, I will ensure that no person under the age of 25 years has access to my marijuana.
20.I agree to the safe storage of my marijuana.
21. I will not use controlled substances that were prescribed by another doctor unless ICTMG Physician and my primary care physician is aware of this.
22. I understand that my physician may not be knowledgeable about all of the risks associated with the use of non-FDA approved substances like marijuana.
23. I accept full responsibility for any and all risks associated with the use of marijuana, including theft, altered mental status and side effects of the product.
24. I am aware that my physician may discontinue authorizing marijuana for my condition if he or she assesses that the medical and mental health risk or side effects are too high.
25. I agree to purchase my marijuana only from a licensed dispensary. I am aware that the possession of marijuana from other sources is illegal.
26. I am aware that any possible criminal activity related to my marijuana use may be investigated by legal authorities. During the course of an investigation, legal authorities have the right to access my medical information with a warrant.
27. ICTMG Physician has the right to discuss my health care issues with other health care professionals or family members if it is felt on balance, that my safety outweighs my right to confidentiality.
CONSENT FOR TELEHEALTH CONSULTATION
• I understand that my health care provider wishes me to engage in a telehealth consultation.
• My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
• I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
• I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
• I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
CONSENT TO USE THE TELEHEALTH BY SIMPLEPRACTICE SERVICE
Telehealth by SimplePractice is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:
• Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
• Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
• The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
• I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.
• To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.
By signing this form, I certify:
• That I have read or had this form read and/or had this form explained to me.
• That I fully understand its contents including the risks and benefits of the procedure(s).
• That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
Notice of Privacy Practices:
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:
• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Give you this notice of my legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect.
• I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.
For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a health care provider were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the health care provider in diagnosis and treatment of your condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard. Because other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.
Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
• Session Notes: I do keep “Session notes” and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For my use in treating you.
b. For my use in training or supervising associates to help them improve their clinical skills.
c. For my use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the session notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.
• Marketing Purposes. As a health care provider, I will not use or disclose your PHI for marketing purposes.
• Sale of PHI. As a health care provider, I will not sell your PHI in the regular course of my business.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:
• When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
• For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
• For health oversight activities, including audits and investigations.
• For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
• For law enforcement purposes, including reporting crimes occurring on my premises.
• To coroners or medical examiners, when such individuals are performing duties authorized by law.
• For research purposes, including studying and comparing the patients who received one form of care versus those who received another form of care for the same condition.
• Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counterintelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
• For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.
• Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
• Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
• The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
• The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
• The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
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THIS SECTION IS FOR SUBOXONE PATIENTS ONLY:
1.I understand that Suboxone is a combination of buprenorphine and naloxone. Nalxone will counter act any opioid I’m taking, causing precipitated withdrawal. I understand I must take Suboxone as ordered and follow instructions outlined.
2.I understand that buprenorphine is a narcotic drug that, if taken in large quantities, can produce a ‘high’. I know that if I abruptly stop taking it, I could experience opioid withdrawal symptoms.
3.My health care team has discussed with me various options for treatment of my addiction, including non-pharmacological options. They have explained, and I understand, the risks and benefits of Suboxone, including potential side effects. I understand that in order to be a satisfactory candidate for Suboxone, I must follow certain safety precautions for the treatment and comply with the treatment the schedule prepared for me by my attending physician and/or my substance abuse counselor. Additionally, my health care team has discussed this agreement with me and explained what is expected of me in the program. I have been given information about the program and have had adequate time to have my questions answered. As a result, I voluntarily consent to the program.
4.I will take Suboxone by placing it under my tongue to dissolve and be absorbed. I will never inject Suboxone or take it intravenously (IV), because IV use could lead to sudden and severe opiate withdrawal.
5.I will not drive a motor vehicle or use power tools or other dangerous machinery while taking Suboxone until my doctor has cleared me to do so.
6.I will inform my MAT provider and care team of all my other doctor and dentist appointments and any medications (prescription or non-prescription) that I am taking. I will also report any change in my medical history.
7.I understand that mixing Suboxone with alcohol or other sedatives (such as Valium, Ativan, Xanax, Klonopin, Librium), benzodiazepines can be dangerous. The result could be accidental overdose, over-sedation, organ failure, coma, or death. I agree to abstain from alcohol and sedatives while I am taking Suboxone. I understand this is important for my safety and to assure that another medication is not prescribed which may lead to harmful side effects.
8.I understand that continued use of other drugs can interfere with my attempts at recovering from opioid dependence. I also understand that buprenorphine (as found in Suboxone) is designed to treat opioid dependence, not addiction to other classes of drugs. Therefore, I will work with the MAT provider to design an individualized treatment program to assist me in discontinuing the use of any other drugs I am using.
9.My medication must be protected from theft or unauthorized use. I understand that Suboxone must be stored safely and securely where it cannot be taken accidentally by children, pets, or be stolen. If my medications are stolen, I will file a report with the police and bring a copy to my next visit. If another person ingests my Suboxone, I will immediately call 911 or Poison Control at 1-800-222-1222. I agree to take full responsibility for the safekeeping of my Suboxone. Lost or stolen Suboxone will not be refilled before the date it was due to be renewed unless I can give the clinic a copy of the police report of the loss. I understand my physician reserves the right to refuse refills.
10.I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without recourse for appeal.
11.If I alter or forge a prescription, I understand that my MAT provider has the right to terminate my care immediately and will inform the pharmacy and legal authorities of this felony act.
12.I agree to participate in a regular program of professional counseling as recommended by my MAT health care team. If the program or counseling substance abuse counselor is located outside of the clinic, I will provide proof of attendance (which may be in the form of a note) at any programs or professional counseling that my MAT health care team recommends at each visit to my MAT care team.
13.I agree to receive support from peers as recommended by the MAT clinic staff and agree to invite significant persons in my life to participate in my treatment.
14.I agree that a network of support and honest communication are important parts of my recovery. I will provide authorization to allow telephone, email, or face-to-face contact between the MAT clinic staff and physicians, therapists, probation or parole officers, the Department of Social Services, and parents to discuss my treatment and progress. I consent to allow the staff of the MAT clinic to provide others with information regarding my medication usage as needed for my treatment or as otherwise permitted or required by law.
15.I understand that buprenorphine can only be prescribed by a specially licensed physician (buprenorphine provider). I can only get buprenorphine refills as scheduled. I will not be able to obtain buprenorphine refills during walk-in visits, after regular clinic hours or on weekends.
16.I must take my medications as instructed by my buprenorphine provider. I cannot change the way I take my medications or adjust the dose until approved by my buprenorphine provider.
17.I agree to see my buprenorphine provider on a regular basis. The frequency of visits will be up to my buprenorphine provider and will be explained to me.
18.If I miss an appointment or if I need to reschedule an appointment for a later date, I understand that my medications will not be refilled until the time of my next scheduled appointment with a buprenorphine provider. I understand that if I miss or am late to three appointments and did not call the clinic in advance and provide at least 24hr notice I will be dismissed from the buprenorphine maintenance clinic and I will not be given any refills for my medication. I may also be given a lower dose, enough to avoid withdrawal.
19.I understand my Suboxone provider will monitor my compliance by counting my Suboxone tablets or films. I agree to bring my Suboxone medication to each Suboxone clinic visit.
20.I understand that I may be asked to bring in my Suboxone medication to be counted at any time and will come into the office within 24 hours of receiving such a request.
21.I understand that my Suboxone provider will monitor my medication compliance by doing urine or blood drug screens at each visit at my cost. I consent to testing for this purpose and I understand that it is a requirement of my participation in the buprenorphine clinic. Drug screens will be “supervised,” and a staff person will be required to be present in the restroom with me in order to ensure that the test specimen is coming from my body.
22.I agree to notify the clinic immediately in case of relapse to opioid drug abuse. Relapse can be life threatening, and an appropriate treatment plan must be developed as soon as possible. I understand the physician should be informed about relapse before any urine test shows it.
23.My provider has recommended that I obtain my Suboxone from a single pharmacy.
24.I agree to conduct myself in a courteous manner in the physician’s or clinic’s offices.
25.I agree to pay all office fees for this treatment at the time of my visits. Failure to do so is cause for immediate termination of services.
26.I understand that if I do not uphold this agreement, I will be dismissed from the program.
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By your electronic signature of this form, you authorize charges to your credit card through Stripe via SimplePractice for services rendered. These charges will appear on your bank/credit card statement as [ICTMG LLC]. You have the right to request a paper copy of this document.
I authorize ICTMG LLC to charge my credit card.
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify ICTMG in writing of any changes in my account information or termination of this authorization.
I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. I acknowledge that credit card transactions could be linked to Protected Health Information.
BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO ALL THE ITEMS CONTAINED IN THIS ENTIRE PAGE