Patient Treatment Contract
As a participant in Buprenorphine treatment for opioid and dependence, I freely and voluntarily agree to accept this contract as follows:
1. I agree to keep and be on time to all scheduled appointments.
2. I agree to adhere to the payment policy outlined by this office.
3. I agree to conduct myself in a courteous manner in the doctor's office.
4. 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 could result in my treatment being terminated without any recourse of appeal.
5. I agree not to sell or share any medications prescribed to me by my treating physician.
6. I agree not to engage in any illegal or disruptive activities during the time I am a patient of Nashville Addiction Clinic, LLC.
7. I understand that if I am found to be engaging in any illegal or disruptive activities by employees of the pharmacy where my prescription medication is filled, my behavior will be reported to my outpatient clinic and could result in my treatment being terminated without any recourse for appeal.
8. I understand that any prescribed medication must be written using an electronic prescribing system and under no circumstances can prescribed medications be phoned into a pharmacy or be written on a paper prescription pad.
9. I understand that during the course of treatment, should I miss a scheduled appointment with my treating physician, this may results in my treating physician being unable to issue my prescribed medication until I return to the clinic.
10. I agree that any and all medication prescribed to me by my treating physician is my responsibility and I agree to store said medication in a locked safe, located in a secure place, that only I have access to.
11. I understand that should my medication become lost or stollen at any time, it will not be replaced regardless of the
12. I agree not to obtain any medications from physicians, pharmacies or other sources outside of this facility, without first discussing such matters first with my treating physician at Nashville Addiction Clinic.
13. I understand that mixing buprenorphine with other medications, especially benzodiazepines, for example, valium, klonopin or xanax, can be dangerous. I also recognize that several deaths have occurred among persons mixing buprenorphine and benzodiazepines, especially if taken outside of the care of a physician, using routes of administration other than sublingual or higher than recommended therapeutic doses.
14. I agree to take my medication as my doctor has instructed and not alter the way I take my medication without consulting my doctor.
15. I understand that should I take my medication in a fashion that differs from my treating physician's instructions, resulting in my being without medication for a period of time lasting through my follow-up appointment, my medication will not be replenished and filled early.
16. I understand that medication alone is not sufficient to treat my addiction, and I agree to participate in counseling, drug screening, and other treatment as discussed and agreed upon with my doctor, specified in my treatment plan.
17. I agree to abstain from alcohol, opioids, marijuana, cocaine and other addictive substances (except nicotine
18. I agree to provide random observed urine samples as required by The State of Tennessee Department of Mental Health and Substance Abuse Services for Office-Based Opiate Treatment Facilities.
19. I understand that it is both required of me and my responsibility to ensure Nashville Addiction Clinic has my correct phone number and or alternative contact number so that I may be reachable for random pill counts, rescheduling, or other
20. I understand that if I have insurance and I have not had a urine drug screen (passing) within a 30-day period and the insurance company requires any Prior Authorization, the doctor's office may decline or refuse to administrate the proper papers to the insurance company.
21. I agree I will not discuss my treatment plan (including treatment medications) or my fees with any other patient in or out of the Clinic. If this activity is reported to any employee or physician, my actions may result in consciences impacting my treatment as a patient of Nashville Addiction Clinic.
22. I agree that if I do not stay in compliance with the office policies; such as multiple phone calls, multiple missed appointments, etc., and do not adhere to these policies it may result in possible discharge or reevaluation of my treatment plan.
23. I agree to pay all late fees, missed appointments or failed urine drug screen fees as required by the doctor’s office. If fees are not paid in full by the required time it may result in my prescription being delayed and it affecting my treatment plan.
24. I understand that violations of the above may be grounds for termination of treatment.
25. I agree to conduct myself in a courteous manner in the doctor’s office.
26. I understand that I may under no circumstances behave in a violent or threatening manner toward other patients or clinic staff.
27. I understand that should I display behavior that is threatening or violent, the police will be called and I may be arrested and prevented from returning.
28. I understand that I am to treat both patients and clinic staff with dignity and respect. I will not raise my voice, and I will not address others with derogatory names or words.
29. Should I come to the Clinic with disposable items, such as drinks or food, I agree to leave those items in my vehicle. If I leave items in the clinic or parking lot for the staff to pick up, this may result in being discharged from the clinic.
30. If I am a smoker, I understand that I may smoke outside of the facility as long as I dispose of my cigarette butts in the provided cigarette disposal tree. I will not leave them on the ground or store them on the windows of the clinic to be picked up later.
31. I agree not to arrive at the office intoxicated or under the influence of drugs, if I do, the doctor will not see me, and I will not be given any medication/prescription as determined by my treating physician.
32. I understand that I may see the counselor and doctor via telemedicine.