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 call or text us at (615) 927-7802.

Completing this form today ensures your Suboxone prescription can be ready at your first visit.

Save and Finish Later
You can save your progress and complete this form later.
Simply scroll to the very bottom of this page and click the "Save" button.
You'll receive an email with a link to continue at a later 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 have been prescribed Suboxone in the past 12 months, we will need the name, address and phone of your most recent Suboxone provider.

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. You'll then move to seeing us every other week for 4 appointments. Afterwhich, you’ll attend monthly appointments.

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 / Clinic Name*

Suboxone Start Date*

Date

Suboxone End Date*

Date

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

Yes

GoogleDoctorFriendOther

I understand and agree to counseling

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.Format: (000) 000-0000.

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.

YesNo

NoYes

Primary Insurance Company Name*

Subscriber ID*

Group Number*

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

This is usually your name

NoYes

Secondary Insurance Company Name*

Secondary Subscriber ID*

Secondary Group Number*

Name of Secondary insurance policy holder*

This is usually your name

Self-Pay Treatment Fees & Billing Cycle

Our self-pay program is designed to be as accessible as possible. We use a flat, all-inclusive rate that covers all treatment services provided during a defined treatment period.

We often explain this using a gym membership analogy:

You may go to the gym once a week or only once during the month, but the cost and billing cycle remain the same.
If you miss a week, the membership does not pause or carry forward unused time.

Similarly, missing an appointment with us does not pause or extend your treatment period. Self-pay fees cover time in treatment, not individual appointments, prescriptions, or visit frequency. The billing cycle remains the same regardless of how often you are seen during that period.

I agree

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*

Format: (000) 000-0000.

House Phone (optional)

Format: (000) 000-0000.

Gender*

Sex - DSM-5

Email Address

example@example.com

Social Security Number*

Required by the State of Tennessee

MarriedSingleLong-term relationshipDivorced / Separated

Years Married or in Long term Relationship*

Times Married*

Times Divorced*

NoYes

Children's Ages*

NoYes

If no, where do they live?*

ie: with a relative

Who currently resides in the home with you?*

NoYes

If yes, who?*

Graduate SchoolCollegeProfessional or Vocational SchoolHigh School

Highest Grade Completed*

NoYes

Name of current or most recent employer*

What type of work?*

For how long?*

NoYes

DWIDrug-relatedDomestic violenceOther

NoYes

PhysicallySexually (including rape/attempted rape)VerballyEmotionally

Have you ever attended group gecovery?*

Rows	Currently Do	Used To	Never
AA
NA
CA
ACOA

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

NoYes

For what reason(s)?*

Please list all medications you currently take*

ie: ibuprofen, aspirin

Please list any known food and/or drug allergies

NoYes

Where and when did these reactions occur?*

ie: At work in 2020

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?*

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?

If you have been prescribed any of the medications listed below within the past 90 days, we are required to coordinate care with the prescriber.

Benzodiazepines	Amphetamines/CNS Stimulants	Other CNS Depressants
Xanax Klonopin Ativan Valium Librium Serax Dalmane Restoril Versed Halcion	Adderall Adderall XR Vyvanse Evekeo Dexedrine ProCentra/Zenzedi Mydayis Desoxyn Focalin Ritalin Concerta Daytrana (patch) Jornay PM Aptensio XR Quillivant XR	Lyrica Neurontin Soma Flexeril Robaxin Skelaxin Zanaflex Ambien Lunesta Sonata Tramadol Trazodone

NoYes

Signature*

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

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?*

IMPORTANT NOTICE FOR METHADONE USERS

If you are currently prescribed more than 30mg methadone daily, you will need to work with your current prescriber to taper down to a minimum of 30mg daily methadone to safely begin Suboxone treatment with our program.

How much Suboxone do you typically take each day?*

How much Heroin do you typically take each day?*

How much Kratom/7-OH/7-Hydroxy 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

NoYes

Other Drug Use History

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

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

Kratom - Method of use:*

Swallow, snort, smoke, inject

Kratom - How often:*

Kratom - For how long?*

Kratom - 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*

Rows	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

Format: (000) 000-0000.

Cellular Telephone*

Format: (000) 000-0000.

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*

Format: (000) 000-0000.

Work Telephone

Format: (000) 000-0000.

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

Format: (000) 000-0000.

Work Telephone

Format: (000) 000-0000.

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*

Rows	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*

Rows	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

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*

Rows	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

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, treatment options, healthcare providers, and healthcare services. If you speak another language, have a physical or mental disability, or do not understand something, reasonable assistance will be provided so you can make informed healthcare decisions.

Information, Privacy, and Confidentiality

You have the right to:

Request correction of information in your medical record. If the facility declines to make a requested correction, you may submit a written statement of disagreement that will become part of your record.
Receive and review the clinic’s Notice of Privacy Practices and ask questions about how your health information is used or disclosed.
Privacy and confidentiality while receiving services, including during telemedicine visits.
Protection of your protected health information except when disclosure is permitted or required by law, including for treatment, payment, and healthcare operations.

Advocacy Services

You have the right to:

Be free from abuse, neglect, exploitation, or harassment.
Access advocacy services. A list of available resources has been provided to you.
Be informed that the facility is required by law to report suspected abuse, neglect, or child abuse to appropriate authorities.

Participation in Treatment Options

You have the right to:

Be informed about your treatment options and participate in decisions about your care.
Receive an individualized treatment plan based on your medical needs.
Accept or refuse treatment services to the extent permitted by law.
Include family members or patient representatives in your care when permitted by law.
Withdraw from services at any time. Medication decisions will be made collaboratively with your treating provider based on clinical judgment and safety considerations.

The goal of treatment is stabilization and improvement in functioning related to opioid use disorder.
Pregnant individuals may receive priority admission when clinically appropriate.

Financial Information

The clinic accepts most major insurance plans. Coverage, copayments, deductibles, and other patient financial responsibilities are determined by the patient’s insurance plan and are the responsibility of the patient.
Patients are responsible for any portion of charges not covered by insurance, including deductibles, copayments, coinsurance, and non-covered services.
Patients without insurance coverage or who qualify based on financial need and other factors determined by the clinic’s policies and procedures may apply for the clinic’s Sliding Scale Program, which adjusts fees based on household income and size. Eligibility requirements and documentation are required to participate in the sliding scale program.
Payment arrangements, including weekly, bi-weekly, or monthly payment options, may be available and may be modified with approval of the clinic.
Patients have the right to receive information regarding fees, billing practices, and financial policies upon request.

Respect and Nondiscrimination

You have the right to considerate, respectful care, and to not be discriminated against by your doctors, nurse practitioner, physician assistants, 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 be informed 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 file a complaint regarding the facility, its staff, or services without fear of retaliation.
Complaints may include concerns about wait times, scheduling, staff conduct, treatment services, or other operational matters.
You have the right to receive a fair and timely review of any complaint.
If a complaint cannot be resolved by the facility, you may contact:
Tennessee Department of Mental Health and Substance Abuse Services Office of Licensure, Phone: 866-777-1250

As a participant in the Telemedicine 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 appointment.

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 may be utilized. The first kind is called a "point of care" screen, or a "POC." This is a rapid drug screen that provides 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 by a third-party laboratory, working with our program. A urine or small volume blood specimen will be collected by the third-party laboratory’s technicians. This process occurs via telemedicine and under direct supervision and instruction. These screens provide our physicians, nurse practitioners, and/or physician assistants with detailed information that cannot be captured using POC drug screening alone. For example, whether or not a patient is taking their prescribed medication, taking the medication at the prescribed dosage, and whether or not there are other substances present within the patient’s body. Additionally, these specialized drug screens test for the presence of adulterants in the specimen, designed to mask or alter its contents.

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

The laboratory conducting the confirmatory drug screens is not the same company as the clinic. 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 it has 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. Confirm with our new patient coordinator whether we can 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 based on the 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 the clinic offers a bundled care, membership-style fee structure for patients who elect to self-pay for treatment services. Under this model, patients pay a flat rate for each twenty-eight (28) day treatment cycle. This fee covers all treatment services provided by the clinic during that period, regardless of how frequently the patient is seen.
Services included in the bundled fee may include medication management by a physician, nurse practitioner, or physician assistant. Individual or group counseling, case management, and point-of-care drug screening.
Fees collected under this structure do not represent a fee per visit or per individual service. The cost of the treatment does not increase or decrease based on the number of appointments or services provided within the treatment cycle. Visit frequency is determined by the patient’s phase of treatment and clinical needs as determined by the treating provider.

Payment Options

The standard monthly rate is $370 every twenty-eight (28) days when paid in full. For payment flexibility, the clinic may allow patients to make installment payments toward the 28-day treatment cycle:

Monthly payment: $370 due every 28 days (payment in full for the treatment cycle)
Bi-weekly payment: $210 due every 14 days (two payments per cycle totaling $420)
Weekly payment: $105 due every 7 days (four payments per cycle totaling $420; available only with clinic approval)

Treatment Cycle Continuity

The twenty-eight (28) day treatment cycle begins on the date payment is due and continues regardless of the number of visits attended or services utilized during that period.
Missed appointments, rescheduled appointments, early medication depletion, inability to attend scheduled visits, or financial hardship do not pause, extend, or reset the treatment cycle.
Failure to attend scheduled appointments or utilize services during the treatment cycle does not relieve the patient of financial responsibility for that treatment cycle.
Patients experiencing financial hardship are encouraged to speak with clinic staff regarding payment options or eligibility for the Sliding Scale Program.

Services Not Included

The bundled treatment fee does not include prescription medications dispensed by a pharmacy or confirmatory laboratory drug testing performed by the clinic’s third-party laboratory partner.

Refunds

I understand that payments made for treatment services are generally non-refundable once a treatment cycle has begun because the clinic operates under a bundled care, membership-style fee structure. Refunds are not provided based on the number of visits attended or services used during the treatment cycle. In limited circumstances, such as administrative error or other extraordinary situations, the clinic may review refund requests on a case-by-case basis. Failure to attend scheduled appointments does not relieve the patient of financial responsibility for the treatment cycle.

By signing below, I acknowledge and agree to the terms outlined above.

Your Signature*

HIPAA Patient Consent Form

The federal government requires all healthcare providers to inform patients of their rights regarding the use and disclosure of their personal health information. Our Notice of Privacy Practice is available for review electronically upon request.

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 electronically upon 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 operations. 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 or disclosed for treatment, payment, and healthcare operations (TPO), including coordination of care with other healthcare providers. (such as your primary care physician or specialist referral), payment with your insurance company or health care operations within our program.
The clinic has a Notice of Privacy Practices that is available for review.
The clinic reserves the right to change its Notice of Privacy Practices and will make the revised notice available upon request.
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.

Your Signature*

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 authorize the clinic to disclose my medical information to the following individuals:

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.Format: (000) 000-0000.

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://recoverycarecolumbia.com/patient-treatment-contract/.

Please read the entire Patient Treatment Contract document thoroughly and then answer the following question. 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 in 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 all questions have been answered satisfactorily.

Your Signature*

Consent to Begin Office-Based Treatment for Opiate Addiction

I approve and direct the treating physician, nurse practitioner, and or physician assistant to perform telemedicine office-based treatment for opioid use disorder 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. The 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 breath and death, especially for children and the elderly. Buprenorphine is a narcotic. The risk of addiction and other effects of the class of narcotics is 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

Pregnancy Considerations

I understand that opioid use disorder during pregnancy may pose risks to both the pregnant woman and the fetus if left untreated. These risks may include miscarriage, preterm birth, low birth weight, fetal growth restriction or other pregnancy complications, and other complications.

I understand that medication treatment for opioid use disorder, including treatment with buprenorphine or Methadone, is considered the standard of care during pregnancy and is recommended over withdrawal management alone because untreated opioid use disorder may pose greater risks.

I understand that if I am currently pregnant or become pregnant while receiving treatment, I should notify the clinic staff and my treating provider as soon as possible so that appropriate medical evaluation, counseling, and documentation regarding treatment during pregnancy can be completed.

If I am pregnant, additional education regarding medication treatment during pregnancy, neonatal abstinence syndrome (NAS), and coordination with obstetric care will be provided.

Pregnancy Testing

Women of childbearing potential are required to undergo monthly pregnancy testing as a condition of enrollment and continued participation in this medication treatment program. This requirement is consistent with clinical best practices and applicable program standards, including those of the Tennessee Department of Mental Health and Substance Abuse Services, BESMART, and other relevant oversight entities.

Pregnancy testing will be conducted in conjunction with required urine drug screening and will occur at intervals of no less than one calendar month. This requirement is necessary to ensure appropriate medical management and coordination of care during medication treatment

Family Planning and Contraception

Patients of reproductive age will be offered education regarding family planning and contraception options. Long-acting reversible contraception (LARC) and other contraceptive methods may be discussed if the patient wishes to avoid unintended pregnancy.

Use of contraception is voluntary. If a patient expresses interest in contraception services, the clinic may provide a referral to an appropriate provider and or the local county health department.
These risks have been explained to me.

Patient Acknowledgement

These considerations have been explained to me. By signing below, I acknowledge that:

I have read and understand this consent form.
During my first appointment, I will/have the opportunity to ask questions about treatment, risks, and available alternatives.
During my first appointment, I will/have addressed all questions to my satisfaction prior to moving forward with treatment.
I understand that should I become pregnant while enrolled in this program, I must notify the clinic immediately.
I voluntarily consent to begin telemedicine office-based treatment for opioid use disorder.

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

Medication selection during pregnancy

I understand that opioid use disorder during pregnancy is associated with increased risks to both the pregnant woman and fetus, including preterm birth, low birth weight, fetal growth restriction, and other pregnancy complications if untreated. Continued illicit opioid use may increase these risks.

I understand that treatment with medication for opioid use disorder during pregnancy is considered the standard of care. Methadone and buprenorphine are both evidence-based treatment options during pregnancy. Medication treatment is recommended over withdrawal management alone. Untreated opioid use disorder during pregnancy is associated with significant risks, including relapse, overdose, infectious disease, inadequate prenatal care, fetal growth restriction, and pregnancy loss.

I understand that medication selection, including formulation (buprenorphine with naloxone and buprenorphine without naloxone), is determined solely by the treating provider after clinical evaluation and review of my medical records. Current clinical evidence indicates that both buprenorphine with naloxone and buprenorphine without naloxone may be used during pregnancy when clinically appropriate. The choice of formulation will be determined by the treating provider based on individual clinical circumstances in keeping with evidence-based practices. Educational materials and intake documents do not constitute a guarantee of a specific prescription or a prescription in general.

I will meet with a physician, nurse practitioner, or physician assistant at the clinic to discuss the risks and benefits of taking medication containing buprenorphine during my pregnancy.

FDA Status

I understand that methadone is approved by the U.S. Food and Drug Administration (FDA) for the treatment of opioid use disorder. Buprenorphine products are FDA-approved for the treatment of opioid use disorder; however, medication labeling may not specifically reference pregnancy. Use of medications during pregnancy is based on available clinical evidence, expert guidelines, and individualized medical decision-making.

Neonatal Abstinence Syndrome (NAS)

I understand that babies exposed to opioids during pregnancy, including methadone or buprenorphine, may experience withdrawal symptoms after birth. This condition is called Neonatal Abstinence Syndrome (NAS).

I understand that NAS is an expected and treatable condition. Symptoms may include irritability, feeding difficulties, tremors, sleep disturbances, vomiting, diarrhea, or seizures. Some infants may require monitoring and, in some cases, medication treatment in the hospital. Not all infants exposed to medication treatment will develop NAS, and when it occurs it can be effectively treated by pediatric specialists.

I understand that coordination with my obstetric and pediatric providers is important to optimize outcomes for both my baby and me.

Breastfeeding

I understand that, in general, breastfeeding is encouraged for women who are stable on medication treatment for opioid use disorder, are not using illicit substances, and do not have other medical contraindications such as HIV infection.

I understand that breastfeeding and skin-to-skin contact may help reduce the severity of NAS symptoms.
I understand that breastfeeding decisions should be made in consultation with my obstetric and pediatric providers.

Postpartum Relapse Risk

I understand that the postpartum period is associated with increased risk of relapse and overdose, and continued treatment and follow-up care are important after delivery.

Pediatric Notification

I understand that the hospital pediatric team should be informed of medication treatment during pregnancy so that my newborn can be appropriately monitored.

Ongoing Care and Coordination

I understand the importance of:

Attending regular prenatal care visits
Informing my obstetric provider of my medication-assisted treatment
Continuing medication treatment as recommended
Participating in behavioral health services as clinically indicated

I understand that discontinuing medication without medical supervision may increase risks to both me and my pregnancy.

Acknowledgement and Consent

By signing below, I acknowledge that:

I have received information regarding medication treatment for opioid use disorder during pregnancy.
I understand the potential risks and benefits of treatment, as well as the risks of untreated opioid use disorder.
I understand that medication selection will be determined by my treating provider based on clinical evaluation.
During the intake appointment with my treating provider, I have/will have/had the opportunity to ask questions, and before the appointment is concluded, have/will have/had all of my questions answered to my satisfaction.
I voluntarily consent to receive medication treatment for opioid use disorder during pregnancy as determined appropriate by my treating provider.

Your Signature*

Your Signature Med Rec

Pharmacy Acknowledgement

I understand that my clinic does not dispense medications of any kind, and is not directly affiliated with any pharmacy in the State of Tennessee.
I understand that my clinic prescribes medications associated only with opioid addiction treatment, and does not prescribe medications for other purposes, illnesses or diagnoses.

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:
1. My pharmacy is accepting new Suboxone patients.
2. My pharmacy has adequate stock of Suboxone medication.
3. 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:
1. The shipping pharmacy will charge me an overnight delivery fee of approximately $14, and is subject to change.
2. 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

Welcome to Group Counseling!

Please read through the information below and feel free to ask questions if you would like further information or clarification. Once you are ready to participate, please sign this informed consent form below so we will have on our records that you have read the information and that you have been properly informed about Group Counseling.

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:

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 counseling, 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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