Consent To Participation In Opioid Parmacotherapy Treatment

STAR CENTER, INC.
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Consent to Participation in Opioid Pharmacotherapy Treatment
Name of Practitioner Explaining Procedures

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Name of Patient:

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Date:

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NAME OF PROGRAM MEDICAL DIRECTOR: Dr. Saleh Ghaith, M.D.
I hereby authorize and give voluntary consent to Star Center, Inc., and its medical personnel to dispense and administer opioid pharmacotherapy (including Methadone or Buprenorphine) as part of the treatment of my addiction to opioid drugs. Treatment procedures have been explained to me, and I understand that this will involve my taking the prescribed opioid drug at the schedule determined by the program physician in accordance with Federal and State regulations. It is been explained that, like all other prescription medications, opioid treatment medications can be harmful if it is not taken as prescribed. Overdoses of methadone are lethal, as can combinations of methadone and other drugs including, alcohol. I further understand that opioid treatment medications produce dependence and, like most other medications, may produce side effects. Possible side effects have been explained to me.
I understand that it is important to me to inform any medical provider who may treat me for any medical problem that I am enrolled in an opioid treatment program so that the provider is aware of all the medications I am taking, can provide the best possible care, and can avoid prescribing medications that might affect my opioid pharmacotherapy or chances my chances of successful recovery from addiction.
I understand that I may withdraw voluntarily from this treatment program and discontinue the use of the medications prescribed at any time. Should I choose this option, I understand I will be offered medically supervised withdrawal.
I further authorize provision of the following: diagnostic assessment, individual and group counseling, medication review and monitoring. My participation is voluntary; I understand that this program follows person-centered planning guidelines and that my treatment plan will be individualized to meet my needs and goals and I will participate in the development of my treatment plan.
For Female Patients of Childbearing Age: There is no evidence that methadone pharmacotherapy is harmful during pregnancy. If I am, or become pregnant, I will inform the program immediately so that I can receive appropriate care and referrals.
This release allows Star Center, Inc. to contact other methadone treatment programs within a 200-mile radius to ensure that I am not dually enrolled.
Signature of Patient
Date of Birth

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STAR CENTER, INC.

Consent to Participation in Opioid Pharmacotherapy Treatment