Patient Treatment Contract

The following patient treatment contract represents the expectations, requirements, and agreements required of all patients. Please read this document thoroughly. If you have any questions pertaining to the content listed below, please contact our staff for further clarification. 

  1. I will keep my medication in a safe and secure place away from children (e.g., in a lockbox). I plan to store my medication in the following way (describe where and in what):
    _____________________________________________________________________________
    (The patient’s answer will be stored in the Patient Treatment Contract Acknowledgement)
  2. I will take the medication exactly as my doctor prescribes. If I want to change my medication dose, I will speak with the doctor first. Taking more than my doctor prescribes OR taking it more frequently than my doctor prescribes is medication misuse and may result in changes to my treatment plan that may include but are not limited to: weekly appointments, medication counts to verify the quantity of medication in my possession, changes in the amount of medication prescribed, or discharge from the program. Taking the medication by snorting or by injection is also medication misuse and will result in my being referred to a higher level of care.
  3. If I’m a self-pay patient, I understand all payment options available through this clinic and promise to adhere to all payment guidelines. I agree to complete all payments for fees owed prior to receiving treatment services through the clinic’s payment link provided to me upon check-in.
  4. If I have a commercial/private insurance plan that is in-network with the clinic’s contracted insurance partners, I am responsible for all copays, coinsurances, TeleMAT fees, and fees deemed “patient responsibility” and agree to pay such fees upon check-in or at such time I am notified by the clinic that said fees are due. Additionally, in the event my insurance coverage undergoes a change or I experience a lapse in coverage (known or unknown to me), I understand that I will be responsible for any and all fees incurred by the clinic as a result. Fees incurred by the clinic must be resolved prior to my next clinic appointment. A lapse in coverage or insurance plan changes resulting in the clinic’s inability to collect reimbursement will result in my transition from insurance coverage to self-pay and include all applicable fees. 
  5. If I have a Tennessee Medicaid plan (BlueCare, Wellpoint (formerly Amerigroup), or United Healthcare Community Plan; I understand that it is my responsibility and my responsibility alone to ensure the clinic has my most up-to-date insurance information. This includes ensuring that I have no other insurance plans, commercial/private or other, without first notifying the clinic. Proper notification must be met with a response from clinic staff either by phone or text affirming receipt of such information. In the event I’m informed of a secondary or tertiary insurance plan listed as my primary insurer, I agree to contact my insurance company immediately to fulfill a coordination of benefits (COB) prior to my appointment and verify this information with the clinic staff. 
  6. I understand that if I have a medication refill scheduled with the clinic, my doctor, nurse practitioner, or the prescriber on call will send my prescription once all requirements communicated to me have been completed.
  7. I will be on time for my appointments (those occurring via TeleMAT or in-office) and be respectful to the office staff and other patients. This includes communication occurring via text message. There is a fifteen-minute grace period for all scheduled appointments. Should I check in after the fifteen-minute grace period, I understand that I will no longer be guaranteed to be seen that day and will be put on a standby list. We will do everything we can to ensure you are seen and taken care of. If we are unable to see you as a standby list patient, we will reschedule you for the soonest available opening (usually takes place within 24 hours).
  8. I understand that as a patient enrolled in either the TeleMAT or in-office treatment program, I will likely experience extended wait times resulting from the multiple steps and services required to fulfill all program requirements. The clinic staff will take all reasonable steps to ensure my appointment is completed in a timely fashion. However, it is important to understand that when considering all aspects of treatment services: check-in, the drug screening process, individual or group counseling sessions (with 30-minute minimum time requirements for individual sessions and 50-minute minimum time requirements for group counseling sessions), appointments with your treating physician or nurse practitioner and potential complications resulting delays; the total time could be anywhere between 1-hour at the fastest or several hours at the longest. 
  9. If I have enrolled in the clinic’s virtual TeleMAT program, I will be subject to guidelines and program requirements specific to treatment delivered by way of telemedicine.
  10. I understand communication with the clinic staff occurs within a HIPAA-compliant communications platform called Spruce Health. It is a mobile application that can be found in your mobile operating system’s application store at no charge to you. It can also be accessed on a desktop or laptop computer via the internet. Due to federal patient privacy laws, I understand that all communications must take place within this platform.

  11. If I am unable to attend my scheduled appointment, I will notify the staff no less than 24 hours in advance. In the event it is not possible to extend notification of at least 24 hours, I will notify the clinic staff at the earliest available time and provide the reason I am unable to attend. I understand that despite providing notification, I may be subject to changes in my treatment plan that impact the frequency at which I’m required to be seen. If I’m found to cancel, modify, or reschedule my appointments on a regular basis, I may be subject to a cancelation fee, and or be referred to another clinic.
  12. If I schedule an appointment and do not call to cancel, I will be classified as a “no-call, no-show.” This may result in a no-call, no-show fee. Should I be found to consistently schedule appointments where I do not attend or provide notice, I may be required to pay a non-refundable fee in order to schedule, or the clinic may refuse service. 
  13. I understand that should I request a new pharmacy be used, I will provide notice ahead of time, or I may be required to wait until my next appointment before I’m able to use the new pharmacy.
  14. I understand that if I use Brentwood Pharmacy (medication by mail), I will be provided an additional document outlining a series of requirements designed to help prevent delays in receiving my treatment medications.
  15. I will keep my doctor or nurse practitioner informed of all my medications (including herbs, vitamins, over-the-counter medications, and those prescribed by a healthcare provider) and medical problems.
  16. I will provide the clinic staff with my most up-to-date contact information, including my home address, phone number, and insurance information. I understand that it is my responsibility to provide this information. In the case of insurance, should I fail to provide notice of a change in insurance coverage, carrier, or plan, resulting in the denial of claims for services I’ve received, I will be financially responsible for the fees incurred by the clinic as a result. 
  17. I agree not to obtain or take prescription medications prescribed by any other doctor without first obtaining permission from my doctor or nurse practitioner to ensure such medication(s) do not interfere with my substance abuse treatment plan. I understand that obtaining medications without first obtaining such permissions may result in weekly appointments and changes in my treatment plan that may include but are not limited to discharge from the program. 
  18. If I am going to have a medical procedure that will cause pain, I agree to let my doctor know in advance so that my pain will be adequately treated. This will include a co-management of care plan between my doctor or nurse practitioner and the healthcare provider performing the medical procedure. I will not attempt to block or prohibit my doctor or nurse practitioner from establishing communication with the healthcare professional responsible for performing my medical procedure.
  19. If I miss or reschedule an appointment, I understand that I will not get more medication until my next office visit. This may result in my being seen weekly or other changes in my treatment plan. I understand if my medication is lost or stolen, my doctor or nurse practitioner is not able to prescribe replacement medication. I will notify the office staff immediately and adhere to the outcomes.
  20. I will not attend appointments intoxicated. Should a relapse occur, I will notify the office immediately.
  21. If being seen via TeleMAT, during the drug screening, counseling, and appointments with my doctor or nurse practitioner, I will ensure I’m in a private location, connected to strong WiFi, without others present, and I will conduct myself in a manner consistent with an appointment that would occur in-office. This means, I will not smoke or vape, consume food or drink, or engage in other behaviors that would otherwise be considered rude or inappropriate. If I’m unsure whether or not a particular behavior would be interpreted as rude, I will ask first without assuming the answer. 
  22. I understand if I’m scheduled to be seen via TeleMAT and either the lab technician, counselor, physician or nurse practitioner attempts to reach me in order to deliver treatment services and I do not answer, I may lose my place in line. This could result in my being rescheduled to another day and deemed to have missed the appointment. In this circumstance, I would be required to redo any treatment services completed already, as to ensure all treatment services are completed on the same day.
  23. I understand that if I’m scheduled via TeleMAT, I will undergo either urine drug screens or small-volume blood tests via HIPAA-secure video communication at every appointment. I understand that any suspected tampering or adulterations to my drug screen will be immediately reported to my doctor, and may delay me from receiving medication(s) In addition, any suspected tampering of my drug screens may delay my receipt of medication(s) until I am retested, either by performing a urine drug screen at a local testing facility at my own expense, or by having to wait up to 5 business days to receive additional testing supplies and being retested. I also understand it is my responsibility to take my sealed drug screen to either a USPS Post Office or USPS “Blue Box” within 24 hours of each appointment. Should I fail to mail my drug screen within 24 hours of my appointment time, I may delay or forfeit receiving medication(s) at my next scheduled appointment. I understand that multiple delayed drug screen mailings may mean the activation of probational TeleMAT treatment, requiring me to furnish the clinic with a USPS shipping receipt within 24 hours of my appointments for all mailed drug screens until further notice or being referred to another clinic.
  24. I understand that it is illegal to give away or sell my medication – this is referred to as diversion. We have a ZERO tolerance policy for diversion, and if found to be engaged in diversion, I will be reported to law enforcement, including the DEA, and any pharmacies where I have filled controlled medications. Additionally, I understand that I will be discharged without being prescribed any additional treatment medication(s) and will not be eligible for readmission.
  25. Violence, threatening language, abusive behavior, or participation in any illegal activity will result in my immediate discharge from the clinic, and I will NOT be eligible for readmission.
  26. I understand that routine and random drug testing is a treatment requirement. Drug testing must be observed in compliance with the Tennessee Department of Substance Abuse Treatment Services. If I’m uncomfortable with urine drug screen observation, I may opt for observation via small-volume blood testing.
  27. I understand that drug testing specimen collection may include, but is not limited to, rapid urine screening, confirmation urine screening, and small-volume blood testing. While I may request a specimen collection type, it is my treating physician or nurse practitioner who decides which method must be utilized to remain compliant with the treatment program.
  28. I will abstain from all non-prescribed, illicit, and addictive substances (other than nicotine). I understand that consuming alcohol may be viewed by my care team as an obstacle to establishing sobriety.
  29. I understand that in Tennessee, THC-containing products are still illegal. This clinic is required by both the state of Tennessee’s Department of Mental Health and Substances Abuse Services as well as all insurance contracted partners, to treat THC as an illegal substance and counsel patients as to that fact. While we as a clinic do not view THC as being on par with other illicit substances such as opioids, methamphetamine, cocaine, etc., there are circumstances where THC can pose an increased risk to a patient. For example, patients prescribed anti-anxiety, anti-depressant, or other mental health medications can experience dangerous side effects as a result of mixing THC-containing products with the aforementioned medication classes. To better understand our stance and policies around THC-containing products, please reach out to clinic staff, and we will discuss this with you in greater detail. 
  30. I understand that randomized “medication counts” are a requirement. When asked by clinic staff, I will comply with any request made to fulfill a medication count and adhere to the instructions provided. If I do not, I understand I will have failed the medication count, and changes in my treatment plan will come as a result.
  31. I understand that there are three primary phases of treatment after my first appointment. My first appointment will be comprised of intake-oriented processes where I will be provided with a better understanding of the program. After my intake appointment has been completed, I will be required to fulfill four consecutive weekly appointments, consisting of drug screening, counseling, case management, and appointments with my doctor or nurse practitioner. I understand that in order to advance week over week, all aspects of my care must be considered “compliant.” This means all my drug screens are consistent with my care plan (if being seen via TeleMAT, all of my drug screens have been scanned by USPS within 24 hours of my appointment), and I’m participating in all of my counseling sessions and appointments with my prescribing provider. I haven’t rescheduled or missed any appointments within this phase of treatment. Once I’ve completed the weekly phase of treatment, I will advance to four bi-weekly appointments. In order to advance through this phase of treatment, I must fulfill all of the requirements listed in my weekly phase of treatment. Once I have completed the bi-weekly phase of treatment, I will advance to monthly appointments. I understand that once I advance to monthly appointments, I will have greater flexibility. For example, if I need to reschedule an appointment, I can do so without consequence as long as it is within seven days. If I’m found to have mailed a drug screen late within this phase of treatment, I may receive a warning if my treating prescriber feels it’s appropriate. If I’m found to be non-compliant, there are some circumstances where I may need to return to bi-weekly visits, while in others, I may be required to return to weekly visits. I understand that any medication prescribed to me will, at a maximum, be written to mirror the phase of treatment I’m in.
  32. I understand that people have died by mixing buprenorphine with other drugs like alcohol and benzodiazepines (drugs like Valium®, Klonopin®, and Xanax®). The prescribers at this facility will not prescribe me benzodiazepines. If I’m prescribed benzodiazepines, I understand that I will be required to complete documentation that facilitates communication between my treating providers to ensure my health and safety. Additionally, I understand that should my doctor or nurse practitioner feel it is unsafe to prescribe a buprenorphine-containing medication such as Suboxone while I am prescribed a benzodiazepine, they will advise me as such. In a circumstance where I am currently prescribed a benzodiazepine or other controlled/scheduled medication, I will help ensure communication is established between all of the prescribers involved in my healthcare treatment. 
  33. I understand that treatment of opioid addiction involves more than just taking my treatment medication. I’m required to participate in all drug screening, counseling, case management, and physician or nurse practitioner appointments. Additionally, I understand that this program is required to perform random medication counts and random drug screens for all patients. Random medication counts and random drug screens occur outside of regularly scheduled appointments. Communication will occur via our HIPAA-compliant application using secure text communication and may include a phone call if not responded to in a timely fashion. In order to remain compliant with this treatment program, I must participate in counseling sessions occurring weekly, bi-weekly, or monthly (as dictated by my phase of treatment). Counseling sessions (both individual and group sessions) have time-bound requirements in order to satisfy state and insurance compliance criteria. If my counselor reports that I’m non-compliant with the counseling appointments (example: I cut the sessions short; or I do not participate in the therapeutic process; or I’m not in a private location), it will have an impact on the frequency I’m required to be seen. I understand that if I continue engaging in non-compliant behavior with counseling appointments, I will be referred out of the facility. 
  34. I understand that buprenorphine is a highly regulated medication and must be treated with extreme care. Buprenorphine is not an appropriate medication for everyone. If I do not meet the diagnostic criteria to be prescribed buprenorphine-containing medications, the doctor or nurse practitioner will not prescribe this medication to me. Additionally, it is important to understand that buprenorphine is addictive and can NOT be abruptly stopped once I start taking it. If I abruptly stop taking buprenorphine, I will experience withdrawal symptoms like those from pain medication, heroin, and or other opioids/opiates. I understand that engaging in buprenorphine medication-assisted treatment is considered a life-saving treatment for individuals suffering from opioid use disorder. Should it be determined by my treating physician or nurse practitioner that buprenorphine-containing medication(s) is medically appropriate as a part of my treatment, I understand that I will be physically dependent on this medication and must be medically tapered off of this medication when deemed appropriate to ensure I do NOT experience withdrawal symptoms. I understand that there isn’t a one-size-fits-all timeline for taking this medication. However, it is common that patients with a multi-year history of opioid dependence will be recommended to establish eighteen to twenty-four months of consistent program compliance prior to initiating a taper plan. In other circumstances, it may be appropriate to establish a timeline well beyond eighteen to twenty-four months, while in other circumstances, it may be less. More important than the amount of time a patient is prescribed this medication is establishing a treatment plan with your care team that you feel comfortable with and is aimed at developing sober momentum for the path ahead. The goal of treatment is to stop using all illicit substances and learn the coping skills necessary for life’s journey so I can become successful in all aspects of my life.
  35. I understand that I may experience opioid withdrawal symptoms when I go off buprenorphine.
  36. I have been educated about the other two FDA-approved medications for opioid dependence treatment, methadone, and naltrexone.
  37. If female and of childbearing age, I have been educated about the increased chance of pregnancy when stopping illicit opioid use and starting buprenorphine treatment and offered methods for preventing pregnancy. 
  38. If female, I understand that I will be required to undergo pregnancy screening on a monthly basis.
  39. If female, I have been educated about the effects of poor diet, illicit opioid use, use of dirty needles/sharing injection equipment, physical and mental trauma, and lack of pre-natal medical, substance use, and mental health care during pregnancy and how these things can adversely affect my health and my current or future fetus/newborn’s health. I understand that neonatal abstinence syndrome can occur when taking illicit opioids and that neonatal abstinence syndrome (NAS) is less severe but can still occur when pregnant women take methadone or buprenorphine as prescribed/dispensed in substance use disorder treatment. Cigarette smoking can make the severity of NAS worse and cause pre-term birth and small babies. Alcohol use can cause significant cognitive/brain damage in fetuses and newborns.

 

Types of Treatment Options

Through recovery, you will be empowered to disrupt addiction's negative effects on your brain and behavior and regain control of your life. There are many treatment paths toward a life of sobriety. We want to help ensure you have all the information necessary to make an informed decision. Knowing all of your available options will help equip you with the information needed to make the right decision for you.

Detoxification (Detox)
Supervised withdrawal from substance use
Medically supervised withdrawal or “detoxification” is the process of taking a person off an opioid on which he or she is physically dependent. The term detoxification is usually called medically supervised withdrawal management to destigmatize the process. The process can be fast or slow and can be done under a variety of levels of care and supervision. “Detox” works differently in different people and in different treatment plans. When supervised by a physician, medications are available to help make this process both safer and more comfortable.

Interim care
When immediate admission to other care isn’t available
Many facilities have long waitlists, but can still help. Interim care provides daily medication and emergency counseling. This can be a helpful bridge from beginning recovery to admission to a regular outpatient, inpatient, or residential setting.

Outpatient
Outpatient treatment is provided within a program site, while the person receiving treatment lives elsewhere (usually at home). Outpatient treatment is offered in a variety of places: health clinics, community mental health clinics, counselors’ offices, hospital clinics, local health department offices, or residential programs with outpatient clinics. Many meet in the evenings and on weekends so participants can go to school or work. Outpatient treatment programs have different attendance requirements. Some programs require daily attendance; others meet only one to three times per week.

Care frequency depends on the program, with some requiring daily attendance and others meeting one to three times per week. Outpatient care usually lasts from about two months to one year.

Intensive Outpatient
Programs like these require a person to attend nine to twenty hours of treatment activities per week. Outpatient programs last from about two months to one year. People who do best in an outpatient program are willing to attend counseling sessions regularly, have supportive friends or family members, have a place to live, and have some form of transportation to get to treatment sessions. 

Hospital inpatient
24/7 care connected to a hospital, lasting days or weeks These are usually connected to a hospital or clinic, and provide detox and rehabilitative care. People with serious mental or medical concerns, as well as substance use disorders, are the most likely to use inpatient treatment. Teens and adolescents benefit from the structure of inpatient treatment to fully understand their needs and make a treatment plan.

Opioid treatment programs (OPTs)
Sometimes known as methadone clinics, this type of treatment program offers medication-assisted outpatient services for individuals dependent on opioid drugs (such as heroin, OxyContin, or Vicodin). These programs use prescription medication, such as methadone or LAAM, to help a person not use illicit opioids. OTPs provide counseling and other services along with administering treatment medication(s).

Residential
Live-in care, lasting for one month to one year
A stable setting for long-term phased treatment. Each facility has specific rules and expectations for both residents and their families. Residential care usually lasts from a few months to a year.

They’re best for people without stable living or work situations and/or who have limited or no family support in treatment. They also help people with very serious disorders who have been unable to get and stay sober or drug-free in other treatment.

Transitional housing
A temporary space to stay while transitioning from an intensive treatment setting. Sometimes called a halfway house or sober living facility.
As part of the path to independent living, these facilities support people in recovery with temporary places to live. They may also have support programs around employment and education, or case managers to help residents succeed during and after their stay.

Co-occurring mental health and substance use treatment
Integrated care that addresses substance use and mental illness
Persons suffering from both substance use and mental health disorders are commonly referred to as suffering from a co-occurring disorder. Approximately half of all people experiencing substance or mental health disorders will also suffer from the other. It is critical that both disorders are addressed to ensure success in recovery. Integrated treatment programs can help. Integrated care brings together different areas of expertise to treat the whole person, and ensure that treatment for one factor doesn’t interfere with treatment of others.

Telemedicine (including internet and mobile options)
Care given over the phone or online to support treatment and recovery
For many, access to telemedicine treatment can be the difference maker between care versus none at all. Individuals who are unable to attend regular appointments scheduled within a traditional treatment facility may find virtual care to be a life-saving option. While it’s not the first step in treatment, telemedicine can be a key part of a treatment plan, especially for patients living far away from a facility. I understand all of the above treatment options outlined above. I would like to proceed with outpatient buprenorphine medication-assisted treatment, pending an evaluation conducted by this facility’s treating clinician, that determines outpatient buprenorphine medication-assisted treatment is the most appropriate treatment option for me.

My signature below serves as my acknowledgment, understanding, and agreement to abide by all the information listed above. 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 accountability, as explained above.