Intake Documents NAC

Submit Your Intake Documents

Welcome!
Thank you for choosing Nashville Addiction Clinic for telemedicine addiction treatment.
Your accurate health history will help us provide you with the best possible care.
Appointments are available every Monday through Friday between 8:30am and 4:00pm. Evening appointments are available every Wednesday until 8:30pm.

Instructions:

Please complete all required sections of this form to the best of your ability.
We will contact you quickly to schedule the soonest available appointment. (You will choose your preferred day and time)
If you have questions or need assistance, please message us at (615) 927-7802.

Choose a Preferred Appointment Time*

Part 1 - Personal Recovery Assessement

Patient's First and Last Name*

First and Last Name are Required

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Date of Birth*

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Staff Initials

Current or Most Recent Suboxone Doctor

If you are currently or were previously prescribed Suboxone, we will need the name, address and phone of your most recent Suboxone provider.

Please Note: Failing to list your current or most recent Suboxone provider may delay your treatment.

Have you ever been prescribed Suboxone?*

NoYes

We know coming from another treatment program is a big step, and we appreciate the opportunity to earn your trust.

While you aren’t new to Suboxone, you are new to us, and we are new to you. This is why it is important that we work together to build a new history. Initially, we’ll need to see you weekly for the first four weeks. Once you’ve completed those appointments, you’ll move to seeing us every other week for 4 appointments. Then, you’ll only need to attend appointments once a month.

Do you have an allergy to Naloxone?*

NoYes

Naloxone Allergies

Currently, we are not accepting patients with a naloxone allergy.
However, you may email us and be placed on a waiting list.

If you are pregnant, have medical proof of your pregnancy, and are currently under the care of an OBGYN, we would be happy to provide you with treatment.

Please tell us about your most recent Suboxone provider:

Suboxone Doctor's Name (required for treatment)*

Label - All Medical Records

Doctor's Name 2

Label - continued medical care

Label - revoke date

Suboxone Doctor Address*

Street Address

Street Address Line 2

CityState

Zip Code

Suboxone Doctor Phone*

Suboxone Start Date*

Date

Suboxone End Date*

Date

Describe in detail the reason you seek Suboxone treatment with us:*

What are some of the things you've lost (or will eventually lose) if you continue abusing drugs?*

Your treatment will require five consecutive weekly visits during your first month of treatment. Can you commit to these preliminary visits?*

Yes

Two-way, crystal-clear audio and video is required for telemedicine treatment. Do you have a mobile device, tablet or computer with a webcam connected to high-speed internet for your appointments?*

Yes

How did you hear about our clinic? (Check all that apply)*

GoogleDoctorFriendOther

An individual or group counseling session lasting 20-30 minutes is required at every appointment.*

I understand and agree to counseling

Do you want us to contact your primary care provider?*

NoYes (will require additional paperwork at your first visit)

Pharmacy Information

Your Suboxone medications can be sent to your local pharmacy or can be mailed to you via overnight delivery using our pharmacy partner.

Delivery Charge: The pharmacy will charge $12 for overnight delivery. They accept all debit and credit cards.

Pharmacy Preference*

Providing us with your local pharmacy's information now will save time at your first appointment.

Preferred Pharmacy Name

Preferred Pharmacy Street Name

Preferred Pharmacy City

Preferred Pharmacy Phone

Please enter a valid phone number.

Part 2 - Insurance Questionnaire

Insurance (Primary and Secondary) Please read carefully: Per House Bill 1980; In the state of Tennessee it is against the law for a patient enrolled in a Medicaid program (Amerigroup, BlueCare, United Healthcare Community Plan) to be treated by a Suboxone clinic and Suboxone prescriber that is NOT contracted with Tennessee Medicaid, and that patient's particular TennCare insurance carrier. This means current enrollees with Tennessee Medicaid must disclose their coverage and may NOT under any circumstances, choose to pay out of pocket. By initialing below, I acknowledge that I have read the above statement pertaining to House Bill 1980 and assert that the information below is true, honest, and current as of today's date. I understand that if I'm found to be dishonest regarding insurance coverage, that my treatment may be terminated with immediate referral out of the program.

Do you currently have health insurance?*

YesNo

Are you currently enrolled in TennCare?*

NoYes

Are you also enrolled in Medicare for persons with disabilities or persons over the age of 65?*

NoYes

Primary Insurance Company Name*

Subscriber ID*

Group Number*

Name of Primary insurance policy holder (typically your own name)*

This is usually your name

Do you have secondary insurance?*

NoYes

Secondary Insurance Company Name*

Secondary Subscriber ID*

Secondary Group Number*

Name of Secondary insurance policy holder*

This is usually your name

Your Signature*

Part 3 - Social, Family & Medical History
Help us get to know you.

Your Home Address*

Patient Address

Street Address Line 2

CityState

Zip

Address for Emergency Contacts*

Patient Address

Street Address Line 2

CityState

Zip

Cell Phone*

House Phone (optional)

Gender*

Sex - DSM-5

Email Address

example@example.com

Social Security Number*

Required by the State of Tennessee

Relationship Status*

MarriedSingleLong-term relationshipDivorced / Separated

Years Married or in Long term Relationship*

Times Married*

Times Divorced*

Do you have children?*

NoYes

Children's Ages*

Do children reside with you?*

NoYes

If no, where do they live?*

ie: with a relative

Who currently resides in the home with you?*

Do you have family nearby?*

NoYes

If yes, who?*

Education (Check most recent degree)*

Graduate SchoolCollegeProfessional or Vocational SchoolHigh School

Highest Grade Completed*

Are you currently employed?*

NoYes

Name of current or most recent employer*

What type of work?*

For how long?*

Have you ever been convicted of a crime?*

NoYes

Please select all that apply:*

DWIDrug-relatedDomestic violenceOther

Have you ever been abused?*

NoYes

How were you abused? (select all that apply)*

PhysicallySexually (including rape/attempted rape)VerballyEmotionally

Have you ever attended group gecovery?*

	Currently Do	Used To	Never
AA
NA
CA
ACOA

If you no longer attend group meetings, what factors led you to stop?

Have you ever been in counseling or therapy?*

NoYes

For what reason(s)?*

Please list all medications you currently take*

ie: ibuprofen, aspirin

Please list any known food and/or drug allergies

Have you ever had an allergic reaction to these foods and/or drugs?*

NoYes

Where and when did these reactions occur?*

ie: At work in 2020

Did any of these allergic reactions result in hospitalization?*

NoYes

Part 4 - Drug Use Summary
Please answer all questions below considering all current and previous drug use, even if no longer actively using.

What is your drug of choice?*

Have you used more of a drug than you meant to or intended?*

NoYes

Have you been unable to cut down on your drug use?*

NoYes

Does using drugs or "chasing" drugs ever take up a great deal of time in your day?*

NoYes

Do you ever feel cravings or a strong desire to use drugs?*

NoYes

Has drug use resulted in failure of meeting obligations or responsibilities at work, home or school?*

NoYes

Has drug use resulted in or worsened social or interpersonal problems with friends, family or others?*

NoYes

Has drug use caused reduction in important social or recreational activities?*

NoYes

Have you used a drug repeatedly in situations where it is physically hazardous (E.G. driving, climbing, being in dangerous situations, etc?*

NoYes

Do you use drugs despite knowing that they are harming you physically or psychologically?*

NoYes

Drug Tolerance: Do you ever need more drugs to achieve the desired effect? (ie: pain relief, feelings of euphoria)*

NoYes

Withdrawals: Do you have signs and symptoms of withdrawals when using less or discontinuing drug use?*

NoYes

Do you ever use drugs to alleviate withdrawal symptoms or cravings?*

NoYes

Have you been treated for substance abuse in the past?

NoYes

When were you treated?

Date

What is the name of the treatment center?

Name of Clinic or Doctor

How long were you in treatment?

Signature*

Past Substance Use
Answers below should reflect all substances you've used in the past.

I have used the following opioids/opiates (check all that apply)*

How did you take the above substances? (check all that apply)*

SwallowSnortSmokeInject

How long did you use the above substances?

Current Substance Use

Answers below should reflect the primary substance you currently use.

Which substance do you currently use most?*

How many milligrams do you typically take in a day?*

How much Suboxone do you typically take each day?*

How much Heroin do you typically take each day?*

How much Fentanyl do you typically take each day?*

Please estimate your daily fentanyl use

When was the last time you used it?*

Date

Do you currently inject?*

NoYes

Other Drug Use History

Describe any other drugs you use or have used in the past.

I use or have used the following drugs (check all that apply):

Alcohol - Method of use:

Alcohol - How often did you drink?*

Alcohol - For how long?*

Alcohol - Date of last use:*

Date

Cocaine - Method of use:*

Snort, smoke or inject?

Cocaine - How often?*

Cocaine - For how long?*

Cocaine - Date of last use:*

Date

Benzodiazepines - Method of use:*

Swallow, snort, smoke, inject

Benzodiazepines - How often?

Benzodiazepines - For how long?*

Benzodiazepines - Date of last use:*

Date

Amphetamines - Method of use:*

Swallow, snort, smoke, inject

Amphetamines - How often?

Amphetamines - For how long?*

Amphetamines - Date of last use:*

Date

Cannabis/THC - Method of use:*

Swallow, snort, smoke

Cannabis/THC - How often?

Cannabis/THC - For how long?*

Cannabis/THC - Date of last use:*

Date

Please share with us anything you feel will help us better understand your substance abuse, both past and current:

Your Signature*

Part 6 - Socrates: Patient Readiness Assessment

Each statement below describes a way that you might (or might not) feel about your drug use. There are a total of 19 statements. Please indicate how much you agree or disagree with each statement by making a selection for each one.

Socrates: Patient Readiness Assessment*

	Strongly Disagree	Disagree	Unsure	Agree	Strongly Agree
I really want to make changes in my use of drugs.
Sometimes I wonder if I'm an addict.
If I don't change my drug use soon, my problems are going to get worse.
I have already started making some changes in my use of drugs.
I was using drugs too much at one time, but I've managed to change that.
Sometimes I've wondered if my drug use it
I have a drug problem
I'm not just thinking about my drug use, I'm already doing something about it.
I have already changed my drug use, and I'm looking for ways to keep from slipping back into my old patterns.
I have a serious problem with drugs.
Sometimes I wonder if I am in control of my drug use.
My drug use is causing a lot of harm.
I am actively doing things now to cut down or stop my use of drugs.
I want help to keep from going back to the drug problems that I had before.
I know that I have a drug problem.
There are times when I wonder if I use drugs too much.
I am a drug addict.
I am working hard to change my drug use.
I have made some changes in my drug use, and I want some help to keep from going back to the way I used before.

Your Signature*

Socrates Re:

Socrates Am:

Socrates Ts:

Part 7 - Emergency Contacts

Home Information

In case of emergencies, please list your personal contact information below.

Home Phone

Cellular Telephone*

Personal Email Address*

example@example.com

Primary Emergency Contact

Please list at least one person you know that we can contact in case of an emergency.

Contact Name*

Relationship to Contact*

ie: friend, brother, spouse, cousin, coworker

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Cellular Telephone*

Work Telephone

Email*

example@example.com

Secondary Emergency Contact (optional)

Optionally, you may list a second person we can contact in case of an emergency.

Contact Name

Relationship to Contact

ie: friend, brother, spouse, cousin, coworker

Address

Street Address

Street Address Line 2

CityState

Zip Code

Cellular Telephone

Work Telephone

Email

example@example.com

Part 8 - DSM-5 Self-Rated Cross-Cutting Symptoms

The questions below ask about things that might have bothered you. For each question, select the number that best describes how much (or how often) you have been bothered by each problem during the past two weeks.

DSM-5 Questionnaire*

	None Not at all	Slight Rare, less than a day or two	Mild Several days	Moderate More than half the days	Severe Nearly every day
1. Little interest or pleasure in doing things?
2. Feeling down, depressed, or hopeless?
3. Feeling more irritated, grouchy, or angry than usual?
4. Sleeping less than usual, but still have a lot of energy?
5. Starting lots more projects than usual or doing more risky things than usual?
6. Feeling nervous, anxious, frightened, worried, or on edge?
7. Feeling panic or being frightened?
8. Avoiding situations that make you anxious?
9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?
10. Feeling that your illnesses are not being taken seriously enough?
11. Thoughts of actually hurting yourself?
12. Hearing things other people couldn't hear, such as voices even when no one was around?
13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?
14. Problems with sleep that affected your sleep quality over all?
15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?
16. Unpleasant thoughts, urges, or images that repeatedly enter your mind?
17. Feeling driven to perform certain behaviors or mental acts over and over again?
18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?
19. Not knowing who you really are or what you want out of life?
20. Not feeling close to other people or enjoying your relationships with them?
21. Drinking at least 4 drinks of any kind of alcohol in a single day?
22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?
23. Using any of the following medicines ON YOUR OWN, that is, without a doctor's prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]?

DSM-5 Average Score

DSM-5 Average Score Label

Part 9 - Patient Health Questionnaire and General Anxiety Disorder (PHQ-9 and GAD-7)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

PHQ-9*

	Not at all	Several days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things.
2. Feeling down, depressed, or hopeless.
3. Trouble falling or staying asleep, or sleeping too much.
4. Feeling tired or having little energy.
5. Poor appetite or overeating.
6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down.
7. Trouble concentrating on things, such as reading the newspaper or watching television.
8. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual.
9. Thoughts that you would be better off dead, or of hurting yourself in some way.

PHQ-9 Total Score

How difficult have the above challenges made it for you to do your work, take care of things at home, or get along with other people?*

Not difficult at allSomewhat difficultVery difficultExtremely difficult

Over the last 2 weeks, how often have you been bothered by any of the following problems?

GAD-7*

	Not at all	Several days	Over half the days	Nearly every day
1. Feeling nervous, or anxious, or on edge.
2. Not being able to stop or control worrying.
3. Worrying too much about different things.
4. Trouble relaxing.
5. Being so restless that it's hard to sit still.
6. Becoming easily annoyed or irritable.
7. Feeling afraid as if something awful might happen.

GAD-7 Total Score

How difficult have the above challenges made it for you to do your work, take care of things at home, or get along with other people?*

Not difficult at allSomewhat difficultVery difficultExtremely difficult

Nice work - You're nearly finished!

Part 10 - Acknowledgements and Disclaimers

The rest of this form will provide you with all information necessary for joining our treatment program. Be sure to read each section carefully and sign your name where needed.

Patient Rights Acknowledgement

Informed Disclosure

You have the right to receive accurate information, in a language you can understand about your health, treatments, health plan, providers, and health care facilities. If you speak another language, have a physical or mental disability, or just do not understand something, you will be helped so you can make informed health care decisions.

Information, Privacy, and Confidentiality

You have the right to request corrected information in your record. If the facility refuses, you may include a written statement of your disagreement to become part of your record.
You acknowledge receipt of the HIPAA Privacy form and have been given the opportunity to ask questions and voice concerns.
You understand that the facility may release protected health information in order to carry out treatment and health care operations.
You have the right to privacy while receiving services.
You have the right to vote, make contracts, buy or sell real estate or personal property, or sign documents, unless the law or court removes these rights.
You have the right to be afforded privacy and freedom for the use of bathrooms when needed.

Advocacy Services

You have the right to advocacy services and the facility has provided a list of these services to you.
You have the right to be free from abuse and/or neglect. If the facility has evidence of abuse, neglect and/or child abuse, the facility must report these situations to the proper entities in accordance with state law.

Participation in Treatment Options

You have the right to know all your treatment options, even if they are not covered by your health plan, and make decisions about your care. Parents, guardians, family members or others that you choose may represent you if you cannot make your own decisions.
You have the right to choose who provides your care.
You have the right to withdraw from services or be maintained on the medication as he or she desired unless medically contraindicated.
You understand that the goal of opioid treatment is stabilization of functioning. You have the right to an individualized treatment plan that meets your individual medical needs from this facility.
You have the right to accept or refuse treatment services.
You will be given priority of admission if you are pregnant.
You have the right to include family members or patient representatives in your care as far as the law allows.

Financial Information (Non-insured customers)

You understand that if paying for treatment you have the option of a weekly, bi-weekly, or monthly payment plan. The payment plan can be changed between these three options at any time by the patient and with the approval of the facility.

Respect and Nondiscrimination

You have the right to considerate, respectful care, and to not be discriminated against by your doctors, other healthcare providers, or health plan representatives.
You have the right to have a relationship with our staff that is based on honesty and ethical standards of conduct, to have ethical issues addressed, and to form you of any financial benefit we may receive if we refer you to another organization, service, or other reciprocal relationship.
You have the right to advocacy services and the facility has provided a list of these services to you.
You have the right to be free from abuse including mental, physical, sexual, and verbal abuse, neglect and all forms of misappropriation and or exploitation.
You have the right to be assisted by the facility in the exercise of your civil rights.
You have the right to participate fully, or to refuse to participate in the community activities, including cultural, educational, religious, community services, vocational, and recreational activities.

Complaints and Appeals

You have the right to a fair, fast, and objective review of any complaint you have against this facility, the doctor, and other health care personnel. This includes complaints including but not limited to wait times, hours available, the facilities, and the conduct of health care personnel.
You have the right to know the results of any complaints you have filed. You havethe right to report complaints that are not able to be resolved to the Department of Mental Health and Substance Abuse Office of Licensure at 866-777-1250.

As a participant in the Office-Based Opiate Treatment Program; I fully understand my patient rights and have been provided a copy.

Your Signature*

No Call / No Show Agreement

I understand that there are a limited number of appointments available on the schedule each clinical day. When I make an appointment to be seen, I understand that there are certain expectations of me as a potential or current patient:

If I’m unable to attend my scheduled appointment, I agree to call with 24 hours notice or I may be charged a late fee of $20.00.*
If I’m going to be late for my scheduled appointment, I agree to call before my scheduled appointment time to make the clinic staff aware that I will be late.
If I’m late, or unable to attend my scheduled appointment due to an interfering event (car trouble, travel, etc), I may be asked to provide proof of such interference.
If I do not call or show, for my scheduled appointment, I will automatically be charged a $20 no call/no show fee, which will be due upon my next call in or office visit.
I also understand that if I have TennCare health insurance coverage, I can arrange for no-cost transportation to and from the clinic.

As a component related to my participation in an outpatient treatment program, I understand the above policies and agree to abide by them without issue or incident.

(*Late fees not applicable to TennCare Medicaid patients)

Your Signature*

Not Applicable to TennCare

Laboratory Billing Consent Form

During the course of your outpatient treatment, two types of drug screens will be utilized. The first kind is called a "point of care" screen, or a "POC." This is a rapid, in office drug screen that provides us with instant results. This type of urine drug screen is included in the flat fee charged for treatment (or if you have TennCare
insurance, these screens are covered by TennCare).

The second type of drug screen we use is called a "confirmation screen." This comprehensive screen is conducted through the third party laboratory, stationed within our clinic. A urine or saliva specimen will be collected. Afterwards you may be asked to fill out some paperwork. These screens provide our physicians with
detailed information, above/beyond POC drug screen testing. For example, whether or not a patient is taking their prescribed medication, taking the medication at the prescribed dosage, whether or not there are other substances in the patients system, or if there are any adulterants in the the specimen, designed to mask it's
contents.

Your physician will decide which drug screen is best for your treatment plan, during each of your appointments. The physician may decide that one or both is necessary. However, this doesn't mean you have done anything wrong. The physician may simply want more information.

The laboratory conducting the confirmatory drug screens is a separate company from Recovery Care. In order to be compliant with federal laws, the lab is required to send a bill for the confirmatory screens (unless you are a TennCare patient, in which case TennCare will cover your drug screens). We know that receiving another bill is not a comfortable experience. We have specifically chosen this laboratory, because they have a patient-friendly billing policy. This means that the laboratory has assured us, that at no time and under no circumstance will a patient ever be reported to a collections agency for delinquent payments on drug screens.

If you have any questions on the drug screening process, point of care screening, confirmatory screening, or billing, please let us know so that we may help resolve any concerns.

Your Signature*

Patient Education Acknowledgement

In accordance with The Department of Mental Health & Substance Abuse Services of Tennessee and BESMART guidelines, we have included patient education materials on HIV, Hepatitis C, overdose reversal agents, and Neonatal Abstinence Syndrome with your new patient packet. Please acknowledge below that you have
received these materials as a part of your treatment.

The following subjects are covered in documents provided to me:

Hepatitis C
HIV
Overdose reversal agents
Neonatal Abstinence Syndrome

My signature below indicates that I have received the materials listed above, understand the contents of these documents, and may inquire further for additional resources and support.

Your Signature*

HIV 101

Without treatment, HIV (human immunodeficiency virus) can make a person very sick and even cause death. Learning the basics about HIV can keep you healthy and prevent transmission.

HIV can be transmitted by:

Sexual contact
Sharing needles to inject drugs
Mother to baby during pregnancy, birth, or breastfeeding

HIV is NOT transmitted by:

Air or water
Saliva, sweat, tears, or closed-mouth kissing
Insects or pets
Sharing toilets, food, or drinks

Protect Yourself From HIV

Get tested at least once or more often if you are at risk.
Use condoms the right way every time you have anal or vaginal sex.
Choose activities with little to no risk like oral sex.
Don’t inject drugs, or if you do, don’t share needles, syringes, or other drug injection equipment.
If you are at risk for HIV, ask your health care provider if pre-exposure prophylaxis (PrEP) is right for you.
If you think you’ve been exposed to HIV within the last 3 days, ask a health care provider about post-exposure prophylaxis (PEP) right away. PEP can prevent HIV, but it must be started within 72 hours.
Get tested and treated for other STDs.

Keep Yourself Healthy and Protect Others If You Have HIV

Find HIV care. It can keep you healthy and help reduce the risk of transmitting HIV to others.
Take your HIV medicine as prescribed.
Stay in HIV care.
Tell your sex or injection partners that you have HIV. Use condoms the right away every time you have sex, and talk to your partners about PrEP.
Get tested and treated for other STDs.

For more information, please visit https://www.cdc.gov/hiv

Your Signature*

Hepatitis C

What is hepatitis?
Hepatitis means inflammation of the liver. The liver is a vital organ that processes nutrients, filters the blood, and fights infections. When the liver is inflamed or damaged, its function can be affected. Heavy alcohol use, toxins, some medications, and certain medical conditions can cause hepatitis. Hepatitis is most often caused by a virus. In the United States, the most common types of viral hepatitis are hepatitis A, hepatitis B, and hepatitis C. Although all types of viral hepatitis can cause similar symptoms, they are spread in different ways, have different treatments, and some are more serious than others.

How is hepatitis C spread?
The hepatitis C virus is usually spread when someone comes into contact with blood from an infected person. This can happen through:

Sharing drug-injection equipment. Today, most people become infected with hepatitis C by sharing needles, syringes, or any other equipment used to prepare and inject drugs.
Birth. Approximately 6% of infants born to infected mothers will get hepatitis C.
Healthcare exposures. Although uncommon, people can become infected when healthcare professionals do not follow the proper steps needed to prevent the spread of blood-borne infections.
Sex with an infected person. While uncommon, hepatitis C can spread during sex, though it has been reported more often among men who have sex with men.
Unregulated tattoos or body piercings. Hepatitis C can spread when getting tattoos or body piercings in unlicensed facilities, informal settings, or with non-sterile instruments.
Sharing personal items. People can get infected from sharing glucose monitors, razors, nail clippers, toothbrushes, and other items that may have come into contact with infected blood, even in amounts too small to see.
Blood transfusions and organ transplants. Before widespread screening of the blood supply in 1992, hepatitis C was also spread through blood transfusions and organ transplants.

Symptoms
Many people with hepatitis C do not have symptoms and do not know they are infected. If symptoms occur, they can include: yellow skin or eyes, not wanting to eat, upset stomach, throwing up, stomach pain, fever, dark urine, light-colored stool, joint pain, and feeling tired. If symptoms occur with a new infection, they usually appear within 2 to 12 weeks, but can take up to 6 months to develop. People with chronic hepatitis C can live for years without symptoms or feeling sick. When symptoms appear with chronic hepatitis C, they often are a sign of advanced liver disease.

Getting tested is the only way to know if you have hepatitis C
A blood test called a hepatitis C antibody test can tell if you have been infected with the hepatitis C virus, either recently or in the past. If you have a positive antibody test, another blood test is needed to tell if you are still infected or if you were infected in the past and cleared the virus on your own.

Hepatitis C can be cured
Getting tested for hepatitis C is important to find out if you are infected and get lifesaving treatment. Treatments are available that can cure most people with hepatitis C in 8 to 12 weeks.

Hepatitis C can be prevented
Although there is no vaccine to prevent hepatitis C, there are ways to reduce the risk of becoming infected.

Avoid sharing or reusing needles, syringes or any other equipment used to prepare and inject drugs, steroids, hormones, or other substances.
Do not use personal items that may have come into contact with an infected person’s blood, even in amounts too small to see, such as glucose monitors, razors, nail clippers, or toothbrushes.
Do not get tattoos or body piercings from an unlicensed facility or in an informal setting.

CDC recommends you get tested for hepatitis C if you:

Are 18 years of age and older
Are pregnant (get tested during each pregnancy)
Currently are or have injected drugs, even if it was just once or many years ago
Have HIV
Have abnormal liver tests or liver disease
Received donated blood or organs before July 1992
Have been exposed to blood from a person who has hepatitis C
Were born to a mother with hepatitis C

Your Signature*

Overdose Reversal Agents

What is an overdose reversal agent?
An overdose reversal agent is a medication, designed to reverse the effects of an overdose.

What is naloxone?
Naloxone is a medicine that rapidly reverses an opioid overdose. It is an opioid antagonist. This means that it attaches to opioid receptors and reverses and blocks the effects of other opioids. Naloxone can quickly restore normal breathing to a person if their breathing has slowed or stopped because of an opioid overdose. But,
naloxone has no effect on someone who does not have opioids in their system, and it is not a treatment for opioid use disorder. Examples of opioids include heroin, fentanyl, oxycodone (OxyContin), hydrocodone (Vicodin), codeine, and morphine.

How is naloxone given?
If someone has overdosed, a naloxone kit can be used to save them. You can get a kit from a specially trained pharmacist without a prescription, but it may not be covered by your medical insurance unless your doctor writes an order. Naloxone is also known by the brand name Narcan. Naloxone is typically available in three
formulations:

Nasal spray (naloxone nasal spray works even if the person is not breathing)
Nasal atomizer spray (naloxone atomizer spray works even if the person is not breathing.
Injection (for instructions, please see page two).

What does an overdose look like?
Three strong signs of overdose are:

Tiny, pinpoint pupils
Slow and shallow breathing
Unconsciousness and/or unresponsiveness

How do I know when to use naloxone?
If you think someone is experiencing an opioid overdose, it does not hurt to give naloxone. Naloxone reverses the effects of opioids such as heroin, methadone, morphine, opium, codeine, or hydrocodone. It does not reverse the effects of other types of drugs like alcohol or stimulants like cocaine. If the person has mixed drugs and an opioid is involved, the person will likely start breathing but continue to be sedated from the other drugs.

How can I tell if it’s working?
If someone is experiencing an opioid overdose and is given naloxone, they should wake up in 2–3 minutes. If the person does not wake up in 3 minutes or loses consciousness again after 30–90 minutes, give them a second dose of naloxone. Stay with the person until help arrives.

Steps for Administering Naloxone

Your Signature*

Financial Responsibility Notification

Understanding Your Financial Responsibility - Insurance and Self-Pay Policies
Our clinic is in-network with most major insurance providers, including Tennessee Medicaid (TennCare). However, patients are responsible for verifying their insurance benefits and coverage before receiving services.

Insurance Patients: If your insurance covers the services provided, we will bill your insurance carrier directly. You are responsible for any copayments, deductibles, or co-insurance as determined by your insurance plan.

We do not accept Medicare as a primary payer at this time.

Non-Covered Services & Private Pay Charges for Insurance Patients
Some services provided by our clinic may not be covered by your insurance plan. These may include:

Counseling services rendered by non-credentialed providers (e.g., LMSWs, LADAC IIs, or counselors working toward permanent licensure).
Additional therapy sessions, case management, or group counseling services beyond what your insurance covers.
Administrative fees, such as telemedicine fees (not all insurance plans cover services rendered via telemedicine), missed appointment fees, or form completion fees (e.g., FMLA paperwork, short-term or long-term disability forms, letters for legal or court purposes, housing or utility assistance, etc.).

You will be responsible for payment upon check-in for your scheduled appointment. Rates may differ from what your insurance company would reimburse.

Sliding Scale Program
In our continued effort to ensure access to life-saving treatment for opioid use disorder patients, we have implemented a Sliding Scale Program for patients without insurance or those opting out of insurance due to economic hardship. Completion of our Sliding Scale Program Application is required and must be accompanied by documentation substantiating the claims made within the application. Discounts and rates are informed by Federal Poverty Guidelines. For more information, or to apply for our Sliding Scale Program, please inquire with clinic staff.

Self-Pay Patients: If you do not have insurance or choose not to use it, you may pay for treatment services under our Self-Pay Fee Structure or if eligible, our Sliding Scale Program.

Self-Pay Fee Structure
I understand that the following fee structure allows for payment flexibility with weekly, bi-weekly, and monthly payment options. I acknowledge that weekly and bi-weekly payment options are created for patient inclusiveness and won’t serve as payment in full for services rendered over the course of twenty-eight days (one-month treatment cycle). Only a monthly payment will serve as payment in full for services issued over twenty-eight days. The clinic provides “bundled care,” which includes point-of-care drug screening, individual and group counseling, case management, and medication management by a physician, nurse practitioner, or physician assistant. Fees for treatment services are intended to cover all services provided by the clinic in either a payment plan: paid weekly, bi-weekly, or in one-month cycles. The fees paid to the clinic do not include prescription medication or confirmatory drug screening performed by our third-party lab partner and do not represent a fee per visit or a fee per service. The frequency in which patients receive treatment services reflects the phase of treatment as decided by the treating provider. Payment for treatment services can be made weekly, bi-weekly, or monthly at any time and do not increase or reduce depending on the level of care. Any medications prescribed by the treating physician will be done so electronically through our e-scribe system and paid for separately through your chosen pharmacy.

Payment Plan Options

Monthly Payment Plan (save $50 with this plan): $370
- Due every 28 days

Bi-Weekly Payment Plan: $210
- Due every 14 days

Weekly Payment Plan (Requires approval through clinic management)
- Due every 7 days

A monthly telemedicine program fee of $20 is required for all commercial insurance holders. TennCare Medicaid insurance holders are not required to pay this fee.

Refunds: I understand that under no circumstances does the clinic issue refunds.

By signing below I understand that I am both agreeing to and acknowledging the terms outlined above.

Your Signature*

HIPAA Patient Consent Form

The federal government requires all medical offices to make patients aware that they have rights regarding the use of their personal health information. Our Notice of Privacy Practice is available for your review at the front desk.

By signing this form, you consent to our use and disclosure of protected health information according to the Notice of Privacy Practices available to you at the front desk or by request. You have the right to revoke this consent at any time, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior consent. The clinic provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operation. This request must be done in writing. Whenever possible we will honor your request.

The patient understands that:

We will not release information to any future doctor, attorney, life insurance company or workers comp company without your written consent.
Protected health information may be used for treatment through one of your current doctors (such as your primary care physician or specialist referral), payment with your insurance company or health care operations within our office.
The clinic has a Notice of Privacy Practices that is available for review.
The clinic reserves the right to change.
The patient has the right to restrict the use of their information, but the clinic does not have to agree to these restrictions if, for example, it interferes with payment, daily operations or providing quality health care.
The patient may revoke this consent in writing at any time and all future disclosures will then cease.
The clinic may condition treatment upon the execution of this consent, for example, you may be required to pay for your visit at the time of service.

Right to Disclose Your Medical Information to a Third-Party
You have the right to authorize other individuals' access to your medical records and personal information. This may include, but is not limited to: medical records, personal information and discussions with clinic staff about your medical treatment. Below, you may list the names of anyone you would like to authorize this access to.

I waive my rights to disclosure to the following people: (optional)

Person's name:

First NameLast Name

Their relationship to you:

ie: brother, mother, friend

Person's name:

First NameLast Name

Their relationship to you:

ie: brother, mother, friend

Recovery Care may leave voice / text messages on this mobile phone number:

Please enter a valid phone number.

Your Signature*

Patient Treatment Contract

The patient treatment contract represents the expectations, requirements, and agreements required of all patients.

Please click the link below to view the Patient Treatment Contract:
https://nashvilleaddictionclinic.com/patient-treatment-contract/

Please read the entire Patient Treatment Contract document thoroughly and then answer the question below. If you have any questions pertaining to its content, please contact our staff for further clarification.

I will store my medication(s) in a safe and secure place away from children (e.g., in a lockbox or safe). I plan to store my medication in the following way:*

Describe "where" and "in what" you will securely store your medications

My signature below serves as my acknowledgment, understanding, and agreement to abide by all the information listed in the Patient Treatment Contract.

I understand that if I’m found to be in violation of the agreements listed in the Patient Treatment Contract, I will be subject to the accountability as described in the document.

Your Signature*

Telemedicine Consent Form

I understand that my health care provider wishes me to engage in a telemedicine consultation.
My health care provider has explained to me how video conferencing technology will be used. I understand these consultations may not be the same as a direct patient/healthcare provider visit due to the fact that I will not be in the same room as my healthcare provider.
I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my healthcare provider or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my health care provider and consulting health care provider in order to operate the video equipment. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room; (3) terminate the consultation at any time.
I have had the alternatives to a telemedicine consultation explained to me, and in choosing to participate on a telemedicine consultation. I understand that some part of my exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care provider.
In an emergency consultation, I understand that the responsibility of the telemedicine consulting specialist is to advise my local practitioner and that the specialist’s responsibility will conclude upon the termination of the video conference connection.
I have had a direct conversation with my doctor, 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 I understand.

By signing this form below, I certify that:

I have read or had this form read and/or had this form explained to me.
I fully understand its contents including the risks and benefits of the procedure(s).
I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

Your Signature*

Consent to Begin Office-Based Treatment for Opiate Addiction

I approve and direct the physicians and/or nurse practitioners at the clinic to perform office-based treatment for addiction for opiates using the medication, buprenorphine.

Use of Buprenorphine for Treatment of Addiction:
In addition to other resources including social support and counseling, I will be treated with medication containing buprenorphine. Medication dose will be adjusted for each patient.

Risks: I understand the medical risks and results including: precipitated withdrawal, which includes nausea, vomiting, diarrhea, constipation, other gastrointestinal issues, goosebumps, anxiety, difficulty sleeping, or dental issues; in some patients these symptoms may increase the risk of heart attack, stroke, or other medical emergencies or conditions. Other unanticipated side effects may also occur. There are also risks to other people if they accidentally or intentionally ingest this medication. These risks include shortness of breaths and death, especially for children and the elderly. Buprenorphine is a narcotic. The risk of addiction and other effects of the class of narcotics are possible with the use of this medication. I also understand that there are general risks with the use of any medication. These risks include but are not limited to: allergic reaction, side effects, injury or death if used improperly - including inappropriate dosing, frequency, ingestion, or use in combination with other sedating medications or substances.

Benefits: I also know that the benefits may include the reduction in cravings, treatment of addiction, lower risk of relapse on illicit drugs; for some, they may be able to gradually use lower doses and may eventually be able to stop this medication.

Other Options Include: Use of no medications during treatment for narcotic addiction; referral to methadone clinic, referral to mental health providers. I have also been told about the risks and consequences of not having treatment: continued addiction or relapse; risk of narcotic withdrawal. I, the patient, have approved the treatment plan. I understand the purpose of this medication. I know the practice of the medication is not an exact science. I know that no guarantee can be made about the outcome.

These risks have been explained to me.

My signature below signifies that:

I have read and understand this consent form.
I have been given all the information I asked for regarding the procedure(s), risks, and other options.
All my questions have been answered.
I agree with everything explained above.

Your Signature*

Consent to Begin Office-Based Treatment for Opiate Addiction for Women

For women: I understand there may be risks during pregnancy. I understand that the withdrawal may increase risk of miscarriage. I understand there may be risks both known and unknown pertaining to Buprenorphine treatment for patients who may be pregnant or might become pregnant.

For patients who are currently pregnant; please notify the front desk and your treating provider as additional documentation on buprenorphine treatment during pregnancy including risks and preventions will be required.
Women of childbearing age are required to undergo one observed drug screen per month to determine a positive or negative pregnancy test. (This will be performed in combination with required observed urine drug screening).
For women who wish to avoid unintended pregnancy, use of Voluntary Reversible, Long-Action Contraception (VRLAC) shall be discussed, and if after discussion VRLAC is desired by the patient, the VRLAC service will be provided, or referral to an appropriate VRLAC provider will be made.

For women who may be breastfeeding: The American Academy of Pediatrics recommends breastfeeding for women taking buprenorphine/naloxone (Suboxone) or methadone as long as moms:

are stable on these medications (doing well in recovery)
are not using illicit drugs
do NOT have HIV infection

Babies born to moms taking buprenorphine/naloxone (Suboxone) - the evidence-based treatment for opioid addiction - may experience withdrawal symptoms after they are born. This is called neonatal abstinence syndrome. NAS is considered expected, common, and treatable. Some babies who experience NAS may require medications (generally morphine) to help them comfortably and safely withdraw.

Breastfeeding and skin-to-skin contact can be used to minimize these side effects. In fact, when moms breastfeed in the hospital after giving birth, the bond and attachment formed between mom and baby have been shown to console the infant, decrease NAS symptoms, and sometimes even prevent the need for medications, thus promoting shorter hospital stays for your baby.

These risks have been explained to me.

My signature below signifies that:

I have read and understand this consent form.
I have been given all the information I asked for regarding the procedure(s), risks, and other options.
All my questions have been answered.
I agree with everything explained above.

Please select the method of birth control used currently:

Current Method of Birth Control

Your Signature*

Patient Consent and Release Form for Buprenorphine Treatment During Pregnancy / Neonatal Syndrome

I, agree to receive substance use disorder treatment from the clinic. During my pregnancy, I agree to be switched from the combination tablet of buprenorphine with naloxone (Suboxone®) to the non-combination buprenorphine tablet (Subutex®) as recommended by national addiction treatment guidelines. My obstetrician will provide my prenatal care. I will meet with a physician at the clinic to discuss the risks and benefits of taking buprenorphine during my pregnancy.

I have been informed that the federal Food and Drug Administration (FDA) has not approved the use of buprenorphine for the treatment of opioid addiction in pregnant women. Whereas, methadone has been FDA approved for the treatment of opioid addiction during pregnancy and there is over 40 years of experience showing methadone treatment to be safe and effective during pregnancy. Therefore, it is currently believed that methadone is safer than buprenorphine for the treatment of opioid addiction during pregnancy.

Although small research studies have been completed in Europe and research is now being conducted in the United States on the effects of buprenorphine on pregnant women and their unborn children, currently there is too little information available to say that buprenorphine is safe during pregnancy.

There have been studies of the effects of buprenorphine on laboratory animals. Buprenorphine has caused some bone problems in laboratory animal embryos and fetuses after injections of buprenorphine but not when the same amount of buprenorphine was given by mouth. A possible problem of taking any opioid (heroin, methadone, or buprenorphine) during pregnancy is that after birth the child may suffer a withdrawal syndrome called Neonatal Abstinence Syndrome. Babies with Neonatal Abstinence Syndrome may suffer from sleep disturbances, feeding difficulties, tremor, sneezing, irritability, vomiting, weight loss, and seizures. A large proportion of these children will require hospitalization, often for long periods of time.

I understand these risks and benefits and have decided to take buprenorphine (Subutex®) rather than methadone. I understand that medical knowledge on the actual or potential risks of buprenorphine on pregnant women and unborn children is not at all certain. I accept responsibility for this decision. On behalf of myself and my unborn child, I hereby release and agree to hold harmless, the program, the prescribing doctor, and the program’s officers, directors, agents, and employees from any liability of any kind which may arise in connection with my taking buprenorphine (Subutex®) during the duration of my pregnancy. As part of ongoing client satisfaction surveys and future research, I understand some information from assessments, evaluations, diagnosis and other portions of my file may be submitted to third parties or utilized by BrightView. I understand that personal identifying information will not be shared, however, general information (age, race, and sex) may be.

Your Signature*

Your Signature Med Rec

Pharmacy Acknowledgement

I understand that my clinic prescribes medications associated only with opioid addiction treatment, and does not prescribe medications for other purposes, illnesses or diagnoses.
I understand that in the event I choose a pharmacy that is unable to dispense my medications, my clinic will have the right to designate a pharmacy of their choosing. If medication delivery is deemed the best option, I will be responsible for paying a small delivery fee.

Regarding Local Pharmacies:
I understand that it is my responsibility to locate a pharmacy near me that is willing to dispense Suboxone medications to me.
I understand that it is my responsibility to verify the following items with my local pharmacy prior to my first appointment:
- My pharmacy is accepting new Suboxone patients.
- My pharmacy has adequate stock of Suboxone medication.
- My pharmacy is willing to dispense Suboxone medications prescribed by a Tennessee, state licensed addiction treatment provider using telemedicine.
I understand that in the event my pharmacy is unable to dispense medications prescribed to me for any reason, it is my responsibility to locate another pharmacy that will.

Regarding Medication Delivery:
As an added convenience, your clinic works with a pharmacy that offers delivery of Suboxone medications to your home address, often eliminating the many obstacles that can occur when working with a local pharmacy.
I understand I may choose to have my Suboxone medications delivered to me, and:
- The shipping pharmacy will charge me an overnight delivery fee of approximately $12.
- The shipping pharmacy will require a brief phone conversation with me prior to shipping my medications.

By signing this form below, I certify that:

I have read or had this form read and/or had this form explained to me.
I fully understand its contents.
I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

Your Signature*

Group Counseling Informed Consent

WHAT IS GROUP COUNSELING?
Group Counseling is a unique type of therapy in which a group of people who are likely experiencing similar challenges share their difficulties and learn new coping skills and tools. As a result, they give and receive help from each other.

We make sure to maintain a safe environment that is conducive to sharing and accepting each other, where everyone can grow and trust one another and feel respected and valued.

CONFIDENTIALITY
We respect each individual's right to privacy and confidentiality. Participation in Group Counseling means that you agree to keep the names and identities of group members confidential. Group Counselors will maintain confidentiality. Should you experience a concern pertaining to confidentiality and your privacy, please reach out to your Group Counselor for assistance. Please be mindful not to engage in any of the following actions:

PLEASE DO NOT:

Ask other members of the group for their personal or contact information. This includes last names, phone numbers, social media usernames, etc.
Seek out members of the group on social media platforms.
Repeat private matters shared by members of the group outside of the group.
Go up to a member of the group, should you see them in a public place. You never know what boundaries each person may have that could be crossed, despite the intention to be kind or polite.
This list does not encompass all scenarios. If you are unsure as to whether an action may breach Group Counseling Confidentiality, please reach out to your Group Counselor for further advice.

ACTIVE PARTICIPATION
Effective Group Counseling requires all participants to actively share thoughts, reactions, and feelings as they arise during group sessions to increase their self-understanding and contribute to the personal growth of other members. To support that goal, Group Counselors will strive to establish and maintain a climate of respect within the group and ask that you do your part to contribute to this as well.

ATTENDANCE
As a reminder, Group Counseling sessions are part of the treatment process. After completing your first two appointments, you will move from Individual Counseling sessions to Group Counseling. Additionally, if you check in for your scheduled appointment outside of the 15-minute grace period, you will need to participate in a Group Counseling Session. Otherwise, we may need to reschedule your appointment for another day. This is due to the impact late arrivals have on the daily schedule.

When attending group, you must keep your video on. The group counselor may intermittently turn on or off your audio to help maintain continuity. It is important to be respectful of other members' sobriety. As such, any individual who may be impaired or thought to be impaired will be removed from the group immediately.

Should you have any technological issues, please be sure to contact a member of our team right away.

RELATIONSHIPS
Members agree to engage group members therapeutically, not socially. The group provides an opportunity to learn about yourself in relation to others, within a therapeutic setting.

GROUP COUNSELORS
Please be respectful of Group Counselors at all times. Conducting a thoughtful and therapeutic Group Counseling session requires a great deal of preparation. Your Group Counselor is here because they care deeply about your therapeutic journey. Your relationship with the Group Counselor is one of a counseling professional and a client.

CONSENT
I agree to the requirements and expectations of Group Counseling as indicated above. I acknowledge that I have had the opportunity to ask questions, and such questions were answered clearly and to my satisfaction.

Your Signature*

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