medication assisted treatment (mat) for opioid use disorders

Buprenorphine is a safe and effective medication used for the treatment of Opioid Use Disorders. If you are struggling with addiction, you may reach out to our office and schedule an evaluation, wherein one of our providers will take a detailed history and determine if you are a candidate for treatment with buprenorphine.

BUPRENORPHINE PROGRAM TREATMENT CONTRACT

As a participant in the buprenorphine treatment for Opioid Use Disorder (OUD), 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.

3. I agree to conduct myself in a courteous manner in the doctor's office.

4. I agree not to sell, share, or give any of my mediation to another person. I understand that such mishandling of my mediation 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 buprenorphine I 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 mediation/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 mediation/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, pharmacies, or other sources without telling my treating physician. 

10. I understand that mixing buprenorphine with other medications, especially benzodiazepines (for example, Valium(R), Klonopin(R), or Xanax(R)), can be dangerous. I also recognize that several deaths have ocurred among personals mixing buprenorphine and benzodiazepines (especially if taken outside the care of a physician, using routes of administration other that sublingual, or in higher than recommended therapeutic doses).

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 at a minimum of twice monthly or more frequently if clinically necessary. 

13. I agree to abstain from alcohol, opioids, marijuana, cocaine, and other addictive substance (with the exception of nicotine).

14. I agree to provide random urine samples and have my doctor test my blood alcohol level. I agree to pay $34.00 for the expenses associated with the process of urine collection for the drug screening analysis. I understand that this fee is not payable by any insurance company and is a separate fee from the cost of the urinalysis.

15. I understand that violations of the above may be grounds for termination of treatment.