Return Patient Intake Packet (0-6 Months)

Our program consists of several phases of treatment, each of which dictate the frequency in which patients are seen, as well as how patients can begin to advance from one phase to the next. Below, we have outlined some of those details to ask you to affirm your understanding and commitment to the requirements:

Induction: If you are returning to us as a transfer patient from another facility, currently prescribed Suboxone, inside the timeframe of your most recent prescription, you may skip Induction. Otherwise, induction will be considered your first appointment. 

Stabilization: Is comprised of four weekly appointments. In order to advance week to week, patients must adhere to all aspects of our treatment program. The following are examples of what would cause a patient in the Stabilization phase not to advance week to week: 

• Missed or rescheduled appointments
• Refusal to participate in counseling or missed counseling appointments
• Drug screens containing prohibited substances, or absent treatment medication
• USPS scanning your specimen mailer beyond the 24-hour mailing cutoff
• Missing or lost drug screening supplies
• Not mailing a drug screen specimen
• Relapse 
• Dosage changes
• Actions that are inconsistent with your Patient Treatment Contract

Bi-weekly Maintenance: This phase consists of four appointments every other week for two months. Patients must adhere to all aspects of our treatment program to advance through each biweekly appointment. The following are examples of what would cause a patient in Bi-weekly Maintenance not to advance, resulting in a return to weekly Stabilization:

• Missed or rescheduled appointments
• Refusal to participate in counseling or missed counseling appointments
• Drug screens containing prohibited substances, or absent treatment medication
• USPS scanning your specimen mailer beyond the 24-hour mailing cutoff
• Missing or lost drug screening supplies
• Not mailing a drug screen specimen
• Relapse 
• Dosage changes
• Actions that are inconsistent with your Patient Treatment Contract

Monthly Maintenance: This phase consists of appointments occurring once each month. To remain in monthly maintenance, patients must adhere to their treatment plan and Patient Treatment Contract. The following are examples of circumstances that could result in either a return to Bi-weekly Maintenance or weekly Stabilization:

• Multiple appointment rescheduling within a 90-day period
• Refusal to participate in counseling or missed counseling appointments
• No call/no show without appropriate documentation as to why notice wasn’t given, or why the appointment wasn’t attended
• Multiple instances of mailing drug screening specimens late
• Missing or lost drug screening supplies
• Not mailing a drug screen specimen
• Relapse
• Drug screens containing prohibited substances, or absent treatment medication
• Dosage changes 
• Actions that are inconsistent with your Patient Treatment Contract

A Drug Screen is Required to Receive Medications

In order to receive medications at your returning appointment, a drug screen is required. 

We can ship a drug screen test kit to your home address (takes 2 to 5 days), or you may purchase (at your own expense) one of the following clinic-approved point-of-care drug screen kits:

• Prime Screen on Amazon - $4.99 (1 to 2 day delivery with Prime)
• Walgreens - $34.99 (Local pickup and free same-day delivery available in most areas)

The federal government requires all medical offices to inform patients that they have rights regarding the use of their personal health information. Our Notice of Privacy Practice is available for 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. 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.

I understand the clinic may leave voice and/or text messages on my mobile phone.

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. (See below)

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:

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

• You understand this facility is self pay and does not accept insurance of any type.
• 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 have the 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.

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:

1. 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.
2. 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.
3. 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. 
4. 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.

Laboratory Billing Consent

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 not the same company as the clinc. 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.

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.

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 correctly every time you have sex, and talk to your partners about PrEP.
• Get tested and treated for other STDs.

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

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

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).

 

Steps for Administering Naloxone:

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. 
Call 911 immediately.

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.

By signing below, I acknowledge I have read and understand overdose reversal agents and steps for administering Naloxone.

Financial Responsibility Notification & Non-Covered Services Acknowledgement

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: $105  (Requires approval through clinic management)
  - Due every 7 days

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

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

Patient Treatment Contract Acknowledgement

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 question below regarding where you'll secure your medication. 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).

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.

Telemedicine Consent Form

1. I understand that my health care provider wishes me to engage in a telemedicine consultation.  
2. 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.
3. 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.
4.  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.
5. 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.
6. 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.
7. 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.

Consent to Begin Office-Based Treatment for Opiate Addiction

I approve and direct the physician 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.

Pharmacy Acknowledgement

1. 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.
2. 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:

1. I understand that it is my responsibility to locate a pharmacy near me that is willing to dispense Suboxone medications to me.
2. 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.
3. 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.

1. 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 $14.
   • 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.

Group Counseling Informed Consent Form

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, 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.