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In case of emergency...

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PLEASE REVIEW THE INFORMATION CAREFULLY:

1. Suboxone is a medication approved by the Food and Drug Administration (FDA) for treatment of people with opioid dependence. Suboxone can be used for detoxification or for
   maintenance therapy. Maintenance therapy can continue as long as medically necessary.
2. Suboxone itself is an opioid, but it is not as strong an opioid as heroin or morphine. Suboxone treatment can result in physical dependence of the opiate type. Suboxone
   withdrawal is generally less intense than with heroin or methadone. If Suboxone is suddenly discontinued, some patients have no withdrawal symptoms; others have symptoms such as muscle aches, stomach cramps, or diarrhea lasting several days. To minimize the possibility of opiate withdrawal, Suboxone should be discontinued gradually, usually over several weeks or more.
3. If you are dependent on opiates, you should be in as much withdrawal as possible when you take the first dose of Suboxone. If you are not in withdrawal, Suboxone may cause significant opioid withdrawal. Some patients find that it takes several days to get used to the transition from the opioid they had been using to Suboxone. During that time, any use of other opioids may cause an increase in symptoms. After you become stabilized on Suboxone, it is expected that other opioids will have less effect.
4. Attempts to override Suboxone by taking more opioids could result in an opioid overdose.
5. You should not take any other medication without discussing it with the medical staff first. Combining Suboxone with alcohol or some other medications may also be hazardous. The combination of Suboxone with benzodiazepine medication such as Valium, Xanax, Klonopin, Librium, and Ativan has resulted in deaths.
6. The form of Suboxone (Suboxone) you will be taking is a combination of Suboxone with a short-acting opiate blocker (Naloxone). If the Suboxone tablet were dissolved and injected by someone taking heroin or another strong opioid, it could cause severe opiate withdrawal.
7. Suboxone tables must be held under the tongue until they dissolve completely. Suboxone is then absorbed over the next 30 to 120 minutes from the tissue under the tongue.
   Suboxone will not be absorbed from the stomach if it is swallowed.
8. Alternatives to Suboxone: Some hospitals that have specialized drug abuse treatment units can provide detoxification and intensive counseling for drug abuse. Some outpatient drug abuse treatment services also provide individual and group therapy, which may emphasize treatment that does not include maintenance on Suboxone or other opiate-like medications. Other forms of opioid maintenance therapy include methadone maintenance.
   Some opioid treatment programs use naltrexone, a medication that blocks the effects of opioids, but has no opioid effects of its own.
9. There are some very important things that you need to know about the medication you are taking called Buprenorphine. In fact, we would like to discuss three things with you right now and then ask you some questions to be sure that you understand.

The four items for discussion are:

1. Being sure that you are not having cravings as you get started with us.
2. Knowing that Buprenorphine has side effects and can interact with other medications and could hurt you.
3. Always use the lowest possible dosage.
4. If you return to your old opioids, your tolerance is lower and you may die.

Let’s begin by talking about making sure that you are not having any cravings. There is some scientific evidence that the dosage of 16 milligrams a day might be safer as a starting dosage to be sure that you are not having any dangerous cravings. We strongly encourage you to wean down slowly, over the next few months.

Secondly, all medications have side effects. And all medications can interact with other medications. Again, we don’t want you to wean down too fast and experience cravings and be tempted to abuse your old opioids, but if you are taking other medications, it is important that you seriously try to wean down below 16mg a day.

Thirdly, and we want to strongly emphasize this point - use the lowest possible dosage of Buprenorphine. You don’t want cravings. And you do not want the withdrawal to return. But you do want as few side effects as possible. Especially if you are taking other medications. But know this, the lower your dosage, the less protection you will have if you do use your old opioids again. And that’s one of the most important things for you to know. As you wean down, and if you abuse the old opioids again, you may die. 

And lastly, and again we want to make this point as strongly as we can, as you wean below 16 milligrams a day, and if you abuse your old opioids again, your tolerance is lower, and you may die.

I also understand that I will be charged $150 per visit unless a lower charge was specified by a MAT’S Clinic employee.

Our Privacy Policy: MAT's Clinic is committed to providing you with quality behavioral healthcare services. An important part of that commitment is protecting your health information according to applicable law. This notice (“Notice of Privacy Practices”) describes your rights and our duties under Federal Law. Protected health information (“PHI”) is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition; the provision of healthcare services; or the past, present or future payment for the provision of healthcare services to you.

Our Duties: We are required by law to maintain the privacy of your PHI, provide you with notice of our legal duties and privacy practices with respect to your PHI, and to notify you following a breach of unsecured PHI related to you. We are required to abide by the terms of this Notice of Privacy Practices. This Notice of Privacy Practices is effective as of the date listed on the first page of this Notice of Privacy Practices. This Notice of Privacy Practices will remain in effect until it is revised. We are required to modify this Notice of Privacy Practices when there are material changes to your rights, our duties, or other practices contained herein.

We reserve the right to change our privacy policy and practices and the terms of this Notice of Privacy Practices, consistent with applicable law and our current business processes, at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. Notification of revisions of this Notice of Privacy Practices will be provided as follows upon request, electronically via our website or via other electronic means, or as posted in our place of business.

In addition to the above, we have a duty to respond to your requests (e.g. those corresponding to your rights) in a timely and appropriate manner. We support and value your right to privacy and are committed to maintaining reasonable and appropriate safeguards for your PHI.

Confidentiality of Substance Use Disorder Patient Records: The confidentiality of substance use disorder patient records maintained by us is also protected by Federal law and regulations. Generally, the law and regulations provide that:

1. We may not disclose to a person outside the treatment center that you are present in the treatment center, that you are a patient of the treatment center, or any information identifying you as having or having had a substance use disorder.
2. Except in specific, limited circumstances described in the federal regulations, we will not disclose any of your substance use disorder patient information to any person outside of the treatment center unless you consent in writing (as discussed below in “Authorization to use or Disclose Confidential Information”).
3. Information related to your commission of a crime on the premises of the treatment center or against personnel of the treatment center is not protected; and
4. Reports of suspected child abuse and neglect made under state law to appropriate state or local authorities is not protected.

See 42 U.S.C. § 290ee-3(2) (c), 42 U.S.C. § 290dd-3(2) (c), and 42 C.F.R. § 2.61 et seq. for Federal Regulations.

Violation of the federal law and regulations by the treatment center is a crime. Suspected violations may be reported to United States Attorney for the judicial district in which the violation occurs as well as to the Substance Abuse and Mental Health Services (SAMHSA) office responsible for oversight of the treatment center.

Uses and Disclosures: Uses and disclosures of your PHI may be permitted, required, or authorized. The following categories describe various ways that we use and disclose PHI. 

Among MAT's Clinic Personnel: We may use or disclose information between or among personnel having a need for the information in connection with their duties that arise out of the provision of diagnosis, treatment, or referral for treatment of alcohol or drug abuse, provided such communication is (i) within the treatment center; or (ii) between the treatment center and MAT'S Clinic. For example, our staff, including doctors, nurses, and clinicians, will use your PHI to provide your treatment care. Your PHI may be used in connection with billing statements we send you and in connection with tracking charges and credits to your account. Your PHI will be used to check for eligibility for insurance coverage and prepare claims for your insurance company where appropriate. We may use and disclose your PHI to conduct our healthcare business and to perform functions associated with our business activities, including accreditation and licensing.

Business Associates: We may disclose your PHI to Business Associates that are contracted by us to perform services on our behalf which may involve receipt, use or disclose of your PHI. All of our Business Associates must agree to: (i) protect the privacy of your PHI; (ii) use and disclose the information only for the purposes for which the Business Associate was engaged; (iii) be bound by 42 CFR Part 2; and (iv) if necessary, resist in judicial proceedings any efforts to obtain access to patient records except as permitted by law.

Crimes on premises: We may disclose to law enforcement officers information that is directly related to the commission of a crime on the premises or against our personnel or to a threat to commit such a crime. 

Reports of suspected child abuse and neglect: We may disclose information required to report under state law incidents of suspected child abuse and neglect to the appropriate state or local authorities. However, we may not disclose the original patient records, including for civil or criminal proceedings which may arise out of the report of suspected child abuse and neglect, without consent.

Court order: We may disclose information required by a court order, provided certain regulatory requirements are met.

Emergency situations: We may disclose information to medical personnel for the purpose of treating you in an emergency.

Audit and Evaluation Activities: We may disclose your information to persons conducting certain audit and evaluation activities, provided the person agrees to certain restrictions on disclosure of information.

Reporting of Death: We may disclose your information related to cause of death to a public health authority that is authorized to receive such information.

Authorization to use or disclose PHI: Other than as stated above, we will not use or disclose your PHI other than with your written authorization. Subject to compliance with limited exceptions, we will not use or disclose psychotherapy notes, use or disclose your PHI for marketing purposes or sell your PHI unless you have signed an authorization. If you or your representative authorizes us to use or disclose your PHI, you may revoke that authorization in writing at any time to stop future uses or disclosures. We will honor oral revocations upon authenticating your identity until a written revocation is obtained. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.

Patient Rights: The following are the rights that you have  regarding PHI that we maintain about you. Information regarding how to exercise those rights is also provided. Protecting your PHI is an important part of the services we provide you. We want to ensure that you have access to your PHI when you need it and that you clearly understand your rights as described below.

Right to Notice: You have the right to adequate notice of the uses and disclosures of your PHI, and our duties and responsibilities regarding same, as provided for herein. You have the right to request both a paper and electronic copy of this Notice. You may ask us to provide a copy of this notice at any time. You may obtain this notice from facility staff or our Privacy Official.

Questions, Requests for Information and Complaints:
For questions, requests for information, more information about our privacy policy or concerns, please contact us. Our company Privacy Official can be contacted at:

MAT's Clinic Attn: Privacy Officer
624 Connell's Park Lane, Suite A1
Baton Rouge, LA 70806
(225) 468-6287

We support your right to privacy of your protected health information. You will not be retaliated against in any way if you choose to file a complaint with us or with the Louisiana Department of Health. 

It is the policy of MAT’S Clinic to drug screen all patients. Patients will be screened at intake as well as periodically and randomly throughout treatment. A positive drug screen is not the cause for immediate termination from the program. However, a positive drug screen could result in a change in your treatment plan. A drug screen may not be covered by your insurance provider. If that is the case, you will be responsible for payment of the urine screen. A refusal to consent to a drug screen will result as “positive” in patient records. Repeated positive drug screens could result in a change in treatment plan and/or termination from the program. All female patients are subject to pregnancy testing through the length of the treatment program.

By signing below I give my consent as a condition of my receiving services at MAT's Clinic, to submit to random and/or reasonable suspicion drug tests. I understand that diagnostic tests and confirmations are billed as additional services and are not included in the cost of clinical services. I further understand that MAT's Clinic utilizes a third-party vendor for testing and reporting on diagnostic tests, which has been specifically designed to provide information not otherwise used by other laboratories and I may receive bills from said third party vendor as determined by my deductible, copayment, and coinsurance and/or if my insurance provider denies all or some of the services billed. MAT's Clinic is not to be held liable for any bills received from said third party vendor.

1. I understand that my health care provider wishes me to engage in a telehealth consultation. 
2. 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. 
3. 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.
4. 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.
5. 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 platform by SimplePractice 

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:

1. Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
2. 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.
3. The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
4. 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.
5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

By signing this consent, 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.

 

This explanation of Medication-Assisted Treatment is intended to provide a general framework for addiction treatment. Ultimately, all medical decisions pertaining to a patient’s course of addiction treatment will be at the MAT's Clinic practitioner’s sole discretion and, by signing below, you acknowledge and agree that your course of addiction treatment may vary from the explanation below.

Intake & Evaluation: You will be given a comprehensive physical exam, substance dependence assessment, and an evaluation of mental status. Assessments are performed to determine the level of treatment needs and appropriateness for treatment. Case management will also begin to coordinate care with outside providers and key individuals in the patient’s environment. Additionally, the clinical team begins to place appropriate referrals to address overall physical, mental, and social health. he pros and cons of the treatment medications recommended will be presented to you. Treatment expectations, as well as issues involved with maintenance and medically supervised tapering off the medication will be discussed.

Stabilization & Maintenance: Providers will manage and optimize medication utilization until patients have discontinued or greatly reduced the use of their drug of abuse, no longer has cravings, and is experiencing few or no side effects. In conjunction with the clinical team, providers make recommendation on level of care, frequency of toxicology studies, treatment planning, and work to conduct the team to facilitate the patient’s completing treatment goals.

Step Down & Aftercare: There are no time limits for treatment. Length of therapy is determined by you and your practitioner. If you and your practitioner agree that the time is right for a medical taper, he or she will slowly lower your dose (known as a taper), taking care to minimize withdrawal symptoms. If you feel at risk for relapse during a taper, let your practitioner know. You can be re-stabilized and continue maintenance if needed. 

Please note: The treatment medicine prescribed may be a narcotic medication indicated for the maintenance treatment of substance use disorder, available only by prescription and must be taken as prescribed. It is illegal to sell or give away your medicine.

If at any time you have questions or concerns about your treatment, please call (225) 468-6287. 

NO-SHOW AND CANCELLATION POLICY

 

This policy has been established to help us serve you better. It is necessary for us to make appointments in order to see our patients as efficiently as possible. It is the policy of the practice to monitor and manage appointment no-shows and late cancellations. MAT’s Clinic’s goal is to provide excellent care to each patient in a timely manner. If it is necessary to cancel an appointment, patients are required to call or leave a message at least 24 hours before their appointment time. To cancel or reschedule an appointment please call MAT’s Clinic at (225) 468-6287.

 “No Show” means you failed to arrive for your scheduled appointment. “Same Day Cancellation” means you cancelled your appointment less than 24 hours before the scheduled appointment time. “Late Arrival” means you arrive at the clinic 15 minutes after the expected arrival time for your scheduled appointment. We understand that situations such as medical emergencies occasionally arise. These situations will be considered on a case-by-case basis.

A fee of $50.00 will be charged for each no show or same day cancellation.