APPOINTED PHARMACY CONSENT

Andrew E. Leifer, M.D., P.C. dba Apex Treatment Services, 1202 Bergen Parkway, Suite 211, Evergreen, CO 80439 Office: 303-674-6074 Fax Line: 303-831-9601

SUBOXONE C (buprenorphine HCI/naloxone HCI dihydrate) sublingual tablet SUBUTEX* C (buprenorphine HCI) sublingual tablet

Patient Name (Print)*

I do hereby authorize Andrew E Leifer MD, at the above address, to disclose my treatment for opioid dependence to employees of the pharmacy specified below. Treatment disclosure most often includes, but may not be limited to, discussing my medications with the pharmacist, and faxing/calling in my buprenorphine prescriptions directly to the pharmacy.

Agree to purchase all SUBOXONE, SUBUTEX, and any other medications related to my treatment from the pharmacy specified below.Agree not to use any pharmacy other than the one specified below for the duration of my treatment with the physician specified above, unless specific arrangements have been made with the physician.Agree to make payment arrangements with the pharmacy specified below in advance of treatment. so that my buprenorphine prescriptions can be filled and either delivered to the office addressed given above or picked- up by employees of the same.

I understand that I may withdraw this consent at any time. either verbally or in writing except to the extent that action has been taken in reliance on it. This consent will last while I am being treated for opioid dependence by the physician specified above unless I withdraw my consent during treatment. This consent will expire 365 days after I complete my treatment. unless the physician specified above is otherwise notified by me.

I understand that the records to be released may contain information pertaining to psychiatric treatment and/or treatment for alcohol and/or drug dependence. These records may also contain confidential information about communicable diseases including HIV (AIDS) or related illness. I understand that these records are protected by the Code of Federal Regulations Title 42 Part 2 (42 CFR Part 2) which prohibits the recipient of these records from making any further disclosures to third parties without the express written consent of the patient. Iacknowledge that I have been notified of my rights pertaining to the confidentiality of my treatment information/records under 42 CFR Part 2. and I further acknowledge that 1 understand those rights.

Patient Signature*

Date*

Date

Parent/Guardian Signature

Parent/Guardian Name (Print)

Witness Signature

Witness Name (Print)

Date

Name

Phone

Address

Confidentiality of Alcohol and Drug Dependence Patient Records The confidentiality of alcohol and drug dependence patient records maintained by this practice/programis protected by federal law and regulations. Generally, the practice/program may not say to a person outside the practice/program that a patient attends the practice/program, or disclose any information identifying a patient as being alcohol or drug dependent unless: 1. The patient consents in writing; 2. The disclosure is allowed by a court order, or 3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or practice/program evaluation. Violation of the federal law and regulations by a practice/program is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations. Federal law and regulations do not protect any information about a crime committed by a patient either at the practice/program or against any person who works for the practice/program or about any threat to commit such a crime.

Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.

Notification of use of Colorado Prescription Drug Monitoring Program This practice subscribes to and uses the Colorado Prescription Drug Monitoring Program, a state-wide, state-run internet based program that tracks all scheduled and DEA-controlled medication prescriptions dispensed by all physicians and pharmacies in Colorado. This program is used to track accountability and monitor prescriptions obtained by patients in this practice.

Patients in this practice are notified of this program and consent to the use of it by this practice.

Patient Signature*

Date*

Date

Parent/Guardian Signature

Parent/Guardian Name (Print)

Date*

Date

Witness Signature

Witness Name (Print)

Date*

Date