Patient Consent/Contract for Treatment:
As a participant in treatment for medications and/or therapy, I freely and voluntarily agree to accept this treatment contract as follows:
1. I agree to keep and be on time to all my scheduled appointments.
2. I agree to adhere to the payment policy outlined by this office. Payments must be made via credit card . Personal checks are NOT acceptable.
3. I agree to conduct myself in a courteous manner during the appointment.
4. I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal.
5. I agree not to deal, steal, or conduct any illegal or disruptive activities in the doctor's office.
6. I understand that if dealing or stealing or if any illegal or disruptive activities are observed or suspected by employees of the pharmacy where my medications are filled, that the behavior will be reported to my doctor's office and could result in my treatment being terminated without any recourse for appeal.
7. I agree that my medication/prescription can only be given to me at my regular office visits. A missed visit may result in my not being able to get my medication/prescription until the next scheduled visit.
8. I agree that the medication I receive is my responsibility and I agree to keep it in a safe, Secure place. I agree that lost medication will not be replaced regardless of why it was lost.
9. I agree not to obtain medications from any doctors, dentists, pharmacies, or other sources without telling my treating physician.
10. I will let my physician know of all medications that I am being currently prescribed including those given by other treatment providers.
11. I agree to take my medication as my doctor has instructed and not to alter the way I take my medication without first consulting my doctor.
12. I understand that medication alone is not sufficient treatment for my condition, and I Agree to participate in counseling as discussed and agreed upon with my doctor and specified in my treatment plan.
13. I agree to abstain from alcohol, opioid, marijuana, cocaine, and other addictive substances.
14. I agree to provide random urine samples or testing (if requested) and have my doctor test my blood alcohol level if necessary.
15. If there is a problem and the patient cannot make the scheduled appointment please call the office and leave a message. Failure to contact the clinic and not showing up at the scheduled appointment may result in a $50.00 fee that will be assessed at the Following visit.
16. We do not take any responsibility for any failure of Insurance Reimbursements. You will be billed for any balances you are responsible for. *Suboxone treatment is a service that is unable to be reimbursed from insurance and is private pay only.
17. You must let your provider or the staff know of any changes in your insurance policy, otherwise you will be responsible for the charges incurred.
18. If you have not been compliant with your treatment visits for a period of 90 days, your case will be considered closed/inactive and be terminated from treatment of which we will send you a notification on the 90th day.
19. If you are terminated from the practice you will not be able to reschedule with our practice. You will be referred to other providers whom provide similar services.
20. I understand that violations of the above may be grounds for termination of treatment.