Patient Intake Form - 22v2

PATIENT SELF- REGISTRATION

Please fill this form to the best of your knowledge. Fields marked with an* are required.
Please have your DRIVER'S LICENSE AVAILABLE. You will need to upload a picture of it to complete this form
You need to have a valid email address to be able to receive notifications about our program
We treat all our patients with respect and expect to be treated the same.
Any disrespectful behavior towards any of our caregivers will result in immediate termination from our program.

START SESSION: ID UPLOAD

HOW TO UPLOAD YOUR DRIVER LICENSE OR STATE ISSUED ID PICTURE:

-Click or tap the Choose file option below.

-Take a picture of your drivers license OR state issued ID

OR

- Upload existing image from your smartphone and select upload when done

Driver license / state issued ID upload*

No File Chosen

File uploads may not work on some mobile devices.

SECTION 1 | DEMOGRAPHICS

Patient Name*

First Name

Middle Name (optional)

Last Name

Home Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Date of Birth*

Gender*

Male Female

Other:

What do you use to prevent pregnancy?*

Email Address*

Cell Phone*

Home Phone

Driver's license state | Federal /State Issued ID state*

Driver's License # | Federal / State issued ID #*

Social Security Number*

Employment*

Employed Unemployed Disabled Retired Student

Occupation*

How did you hear about our program?*

Youtube Ad Street Sign Word of mouth Facebook Internet Search Emergency Text Message Dr John's Medical Website

Other:

Are you a new patient?*

I am a new patient. I have never been in your program I was in your program in the past and would like to rejoin I am a current patient doing my follow-up

SECTION 2 | MEDICAL EMERGENCY

When a person is in a medical emergency, it changes the provider/patient relationship. The emergency allows us to help you faster and more effectively. But it is very important that the emergency situation is properly documented. *

I agree

We understand that opioid withdrawal is a true medical emergency situation and can kill a person. We also understand that buying illegal opioids off the street can expose you to the risk of death from fentanyl. So we also consider having to buy opioids off the street to be an emergency situation.*

I agree

We also understand that if you are on buprenorphine and your access to buprenorphine is suddenly stopped, you will go back into withdrawal and that would be yet another emergency situation. So, anyway you look at it, unless our people are given rapid access to buprenorphine, our people are going to be in an emergency situation. Furthermore, unless the buprenorphine is continued regularly, our people are going to be in an emergency situation. *

I agree

Are you in an emergency situation right now? IMPORTANT: We only treat people in an emergency situation. It is our opinion that anyone who needs access to buprenorphine is in some type of an emergency situation. We are just trying to help each of our people understand what type of situation they are dealing with. *

Yes

Which of these best describes your current emergency situation?*

1). I am in withdrawal. 2). I am not in withdrawal because I am buying opioids off the street. 3). I am currently on buprenorphine and I am not in withdrawal. But if I do not continue to take the buprenorphine, I will run out and go back into withdrawal and possibly be forced to begin buying opioids off the street.

Other:

SECTION A | INTAKE SUMMARY

I have thoroughly reviewed the patient’s medical intake form for their current conditions, past history, and other details. Patient and provider additional remarks about the program, telemedicine or Buprenorphine:*

Yes No

Patient and provider additional remarks *

SECTION B | DIAGNOSIS AND PROGRAM ELIGIBILITY

Diagnosis*

Autonomic Dysfunction Abstinence syndrome with autonomic conflict Adult abstinence syndrome Long term current use of opioid analgesic causing autonomic conflict

Other:

Is the patient a good candidate for the program?*

Yes No

Patient not eligible for the program notes:*

SECTION C | MEDICATION

Suboxone 8 mg / 2 mg sublingual film*

Buprenorphine 8 mg / 2 mg sublingual film*

Suboxone 4 mg / 1 mg sublingual film*

Buprenorphine 4 mg / 1 mg sublingual film*

Suboxone 2 mg / 0.5 mg sublingual film*

Buprenorphine 2 mg / 0.5 mg sublingual film*

Suboxone 8 mg / 2 mg Tablets*

Buprenorphine 8 mg / 2 mg Tablets*

Suboxone 4 mg / 1 mg Tablets*

Buprenorphine 4 mg / 1 mg Tablets *

Suboxone 2 mg / 0.5 mg tablet*

Buprenorphine 2 mg / 0.5 mg tablet*

Subutex 2 mg sublingual tablets*

Buprenorphine 2 mg sublingual tablets*

Subutex 8 mg sublingual tablets*

Buprenorphine 8 mg sublingual tablets *

Zubsolv 0.7mg / 0.18 mg tablets*

Zubsolv 0.7mg / 0.18 mg tablets | 1 tablet daily | #30 Zubsolv 0.7mg / 0.18 mg tablets | 1 tablet BID | #60

Zubsolv 1.4mg / 0.36 mg tablets*

Zubsolv 1.4mg / 0.36 mg tablets | 1 tablet daily | #30 Zubsolv 1.4mg / 0.36 mg tablets | 1 tablet BID | #60

Zubsolv 2.9mg / 0.71 mg tablets*

Zubsolv 2.9mg / 0.71 mg tablets | 1 tablet daily | #30 Zubsolv 2.9mg / 0.71 mg tablets | 1 tablet BID | #60

Zubsolv 5.7 mg / 1.4 mg tablets*

Zubsolv 5.7 mg / 1.4 mg tablets | 1 tablet daily | #30 Zubsolv 5.7 mg / 1.4 mg tablets | 1 tablet BID | #60

Refill*

0 1

SECTION D | PROVIDER'S SIGNATURE

Provider's name*

Larry Boyd Stephanie Brown Sharen Orso Vicky Duhaime Renee Denobrega Delicia Vanterpool Nancy Long

Other:

Today's Date/Time*

:

Provider's signature: During my synchronous telemedicine visit with this patient their history was obtained and evaluated; The risks and benefits of treatment with buprenorphine was discussed; A treatment plan was determined, and the proper diagnosis was established; The patient was given an opportunity to have all questions addressed and answered to their satisfaction, and a prescription was sent to the pharmacy if admitted to the program.*

[clear]

Use your mouse or finger to draw your signature above

SECTION 3 | PHARMACY INFORMATION

IMPORTANT: We do not use CVS or Walmart pharmacies

Preferred Pharmacy name *

Preferred Pharmacy Phone*

Preferred Pharmacy Address*

Address Line 1

Address Line 2

City

State

ZIP Code

SECTION 4 | PRIVATE INSURANCE AND MEDICAID

Do you have primary insurance? *

Yes No

Do you have secondary insurance?*

Yes No

Do you have Medicaid?*

Yes No

IMPORTANT: How are you planning on paying for your medication?*

My insurance will cover my medicines Self-pay Medicare Medicaid

Other:

SECTION 4A | PRIMARY INSURANCE INFORMATION

Why are we asking for this information since your program does not take PRIVATE INSURANCE?

Our program does not take PRIVATE INSURANCE. However, we ask for this information because in most cases your insurance will cover your medication and your insurance requires us to provide this information. This is what's commonly refer to a PA (Prior Authorization).

Insurance Company Name*

Policy Holder Name / Subscriber name*

First Name

Middle Name (optional)

Last Name

Policy Holder Date of Birth*

Subscriber ID*

Group (optional)

Date Issued*

Patient relationship to Policy Holder*

Self Spouse / Significant other Parent(s)

Other:

INSURANCE CARD PICTURE UPLOAD: Upload a picture of your insurance card by selecting the Choose file option below. You can also take upload an existing picture from your phone or take one with your phone camera.

No File Chosen

File uploads may not work on some mobile devices.

SECTION 4B | SECONDARY INSURANCE INFORMATION

Why are we asking for this information since our program does not take SECONDARY INSURANCE?

Our program does not take SECONDARY INSURANCE. However, we ask for this information because in most cases your insurance will cover your medication and your insurance requires us to provide this information. This is what's commonly referred as a PA (Prior Authorization).

Insurance Company Name*

Policy Holder Name / Subscribers name*

First Name

Middle Name (optional)

Last Name

Policy Holder Date of Birth*

Subscriber ID*

Group (optional)

Date Issued*

Patient Relationship to policy Holder*

Self Spouse / Significant other Parent(s)

Other:

INSURANCE CARD PICTURE UPLOAD: Upload a picture of your insurance card by selecting the Choose file option below. You can also take upload an existing picture from your phone or take one with your phone camera. - Copy

No File Chosen

File uploads may not work on some mobile devices.

SECTION 4C | MEDICAID INFORMATION

Why are we asking for this information since our program does not take MEDICAID?

Our program does not take MEDICAID. However, we ask for this information because in most cases your insurance will cover your medication and your insurance requires us to provide this information. This is what's commonly referred to a PA (Prior Authorization).

Recipient Name*

First Name

Middle Name (optional)

Last Name

Recipient ID*

Recipient Date of Birth*

Issued date*

Primary care provider name (Optional)

First Name

Middle Name (optional)

Last Name

Primary care provider address (Optional)

Address Line 1

Address Line 2

City

State

ZIP Code

Primary provider care phone number (Optional)

MEDICAID CARD PICTURE UPLOAD: Upload a picture of your insurance card by selecting the Choose file option below. You can also take upload an existing picture from your phone or take one with your phone camera. - Copy - Copy

No File Chosen

File uploads may not work on some mobile devices.

SECTION 5 | EMERGENCY CONTACT

Emergency Contact*

First Name

Initial (optional)

Last Name

Relationship to the patient*

Parent Child Sibling Grandparent Spouse / Significant other

Other:

Emergency Cell Phone*

Emergency Home Phone

SECTION 6 | CURRENT CONDITIONS

What is your current condition?*

I have an addiction / dependency on Heroin I have an addiction / dependency on Fentanyl I have an addiction / dependency on Pills

Other:

Are you in withdrawal now?*

No. But will be soon. Yes. Just beginning. Yes. Moderate Yes. Severe

SECTION 7 | SUBSTANCE ABUSE HISTORY

How long ago was your last substance usage? *

Did you begin taking the opioids for a medical condition, meaning that they were prescribed to you, or did you start taking the opioids without a prescription?*

I started taking the opioids under medical care and with a prescription for opioids. I started opioids without medical supervision and without a prescription.

Did you take opioids including fentanyl, heroin, oxycodone for any period of time? (Either legal by prescription or illegal off the street).*

Yes No

How long would you estimate that you took any of the above? *

When you tried to stop any of the above, did you get sick? *

Yes No

How old were you when you first used a substance and/or opioids? ?*

Child (0-12) Teenager (13-18) Young adult (19-25) Adult (26-40) Older adult (41 and above)

What led you to take these substances ? How did you get started on Opioids? Please type your answer*

Have you ever overdosed?*

Yes No

Do you understand the limitations of telemedicine *

Yes, I understand

SECTION 8 | BENZODIAZEPINES USAGE

How many times have you overdosed?*

We know that the opioids have done some damage to your DNA, that means to your body. We are concerned that the buprenorphine could still be doing some of this type of damage. Therefore, we want to make sure that you are always taking the least amount that is effective. Do you understand what I'm saying?*

Yes No

For your benefit, we prefer to use the minimum amount of medication. We will not go over 16 mgms a day. Most of our people start with us on either 16, 12, or 8 mgms a day. Some people are already on less than 8 mgms per day. What do you think would be the best starting dosage for you?*

16 mgms 12mgms 8 mgms 4 mgms 2 mgms

Other:

SECTION 9 | MEDICAL HISTORY

Are you currently taking Buprenorphine?*

Yes No

Current Buprenorphine dose *

Less than 4 mgms a day 4 mgms a day 8 mgms a day 12 mgms a day 16 mgms a day 24 mgms a day 32 mgms a day More than 32 mgms a day

What other medications are you currently taking?*

Pregnancy status*

I am currently pregnant I am not pregnant

Do you have any of the following conditions?*

HIV Hepatitis C Seizures Allergies None of the above

Other:

Are you currently taking any HIV medications?*

Yes No

Are you currently taking any Hepatitis-C medications?*

Yes No

Are you currently taking any seizure medications?**

Yes No

Please list your allergies*

Are you over the age of 60?*

Yes No

Do you have any chronic illnesses such as heart disease, high blood pressure, asthma, emphysema, or abnormal heart rhythm?*

Yes No

Do you understand that there is an increased risk associated with any controlled substance and including buprenorphine over the age of 60?*

Yes, I understand

Do you understand that there is increased risk associated with buprenorphine and some medications and that this risk is greater as you get older?*

Yes, I understand

Do you understand that once you are taking Buprenorphine that your tolerance to the opioids will fall and if you return to the opioids that you have a much higher risk of death by overdose.*

Yes, I understand

Do you understand that you must be in at least moderate withdrawal before you start the Buprenorphine?*

Yes, I understand

Do you understand that as you begin with Buprenorphine, there is some scientific evidence that there may be less cravings at 16 mgms a day?*

Yes, I understand

Do you understand that all medications, including Buprenorphine, can have side effects?*

Yes, I understand

Do you understand that all medications, including Buprenorphine, can interact with each other in ways that could harm you?*

Yes, I understand

Do you understand that we believe strongly that you should be taking the smallest dosage possible of Buprenorphine but not so low that you are experiencing symptoms of withdrawal or cravings?*

Yes, I understand

Do you understand that as you are on Buprenorphine, your tolerance to the old opioids you were taking is lower and if you abuse your old opioids you may die?*

Yes, I understand

SECTION 10 | PAST PSYCHIATRIC HISTORY

Have you been diagnosed with other medical conditions by a medical provider? *

Yes No

Please check all that apply: Have you been diagnosed by a medical provider with any of the following? *

Schizophrenia Bipolar disorder Depression None of the above

Have you ever attempted suicide?*

Yes No

Do you hear voices?*

Yes No

Do you want to harm yourself or others?*

Yes No

SECTION 11 | ADDICTION TREATMENT

Have you ever been to (Check all that apply)*

Suboxone / Buprenorphine Methadone Clinic Alcohol Rehab Program 12-Step program In-patient rehab None of the above

SECTION 12 - SURGICAL HISTORY

Have you had any surgeries in the past?*

Yes No

Please list all your major surgeries*

SECTION 13 | FAMILY HISTORY

Do you have any close relatives with addiction?*

Yes No

Is your mother living or deceased?*

Alive Deceased

Mother's medical conditions

Is your father living or deceased?*

Alive Deceased

Father's medical conditions

Number of siblings *

Siblings Medical conditions

How many children do you have?*

SECTION 14 | SOCIAL HISTORY

Do you drink alcohol?*

Yes No

How many alcoholic drinks per day do you drink?*

1 2 3 more than 4

How long have you been drinking?*

Do you smoke?*

Yes No

How many cigarettes do you smoke per day?*

How long have you been smoking?*

Do you vape?*

Yes No

Nicotine cartridge's strength *

0 mg 3mg 6mg 12mg 18mg More than 18 mg 36mg

Other:

How much do you vape a day?*

1 time 2 times 3 times 4 times 5 times more than 5 times

Other:

SECTION 15 | LEGAL HISTORY

Have you ever been arrested for selling or possessing drugs or drug-related crime?*

Yes No

SECTION 16 | WITHDRAWAL SIMPTOMS

Are you currently in withdrawal?*

Yes No

How many days have you been in withdrawal?*

What type of opioid was your last dose?*

Heroin Fentanyl Methadone Hydrocodone Oxycodone Buprenorphine Kratam

Other:

When was your last dose?*

:

In the past 7 days, have you taken any illegal or non-prescribed opioid heroin, pills, fentanyl.?*

Yes No

In the past 7 days, have you overdosed on opioids?*

Yes No

AUTONOMIC DYSFUNCTION SCALE: Please rate the following questions from 0 to 5. 0 Means no symptoms and 5 means strong symptoms

AUTONOMIC DYSFUNCTION SCALE: Please rate the following questions from 0 to 5. 0 Means no symptoms and 5 means strong symptoms
	0	1	2	3	4	5
1. I am yawning more than normal	AUTONOMIC DYSFUNCTION SCALE: Please rate the following questions from 0 to 5. 0 Means no symptoms and 5 means strong symptoms : 1. I am yawning more than normal (0)	1. I am yawning more than normal (1)	1. I am yawning more than normal (2)	1. I am yawning more than normal (3)	1. I am yawning more than normal (4)	1. I am yawning more than normal (5)
2. My eyes are watering more than normal	2. My eyes are watering more than normal (0)	2. My eyes are watering more than normal (1)	2. My eyes are watering more than normal (2)	2. My eyes are watering more than normal (3)	2. My eyes are watering more than normal (4)	2. My eyes are watering more than normal (5)
3. My nose is running more than normal	3. My nose is running more than normal (0)	3. My nose is running more than normal (1)	3. My nose is running more than normal (2)	3. My nose is running more than normal (3)	3. My nose is running more than normal (4)	3. My nose is running more than normal (5)
4. I am having stomach cramping	4. I am having stomach cramping (0)	4. I am having stomach cramping (1)	4. I am having stomach cramping (2)	4. I am having stomach cramping (3)	4. I am having stomach cramping (4)	4. I am having stomach cramping (5)
5. I am vomiting	5. I am vomiting (0)	5. I am vomiting (1)	5. I am vomiting (2)	5. I am vomiting (3)	5. I am vomiting (4)	5. I am vomiting (5)
6. I have diarrhea	6. I have diarrhea (0)	6. I have diarrhea (1)	6. I have diarrhea (2)	6. I have diarrhea (3)	6. I have diarrhea (4)	6. I have diarrhea (5)
7. I am sweating more than normal	7. I am sweating more than normal (0)	7. I am sweating more than normal (1)	7. I am sweating more than normal (2)	7. I am sweating more than normal (3)	7. I am sweating more than normal (4)	7. I am sweating more than normal (5)
8. The hair on my body is standing on end	8. The hair on my body is standing on end (0)	8. The hair on my body is standing on end (1)	8. The hair on my body is standing on end (2)	8. The hair on my body is standing on end (3)	8. The hair on my body is standing on end (4)	8. The hair on my body is standing on end (5)
9. My heart is beating hard and fast	9. My heart is beating hard and fast (0)	9. My heart is beating hard and fast (1)	9. My heart is beating hard and fast (2)	9. My heart is beating hard and fast (3)	9. My heart is beating hard and fast (4)	9. My heart is beating hard and fast (5)
10. I feel anxious	10. I feel anxious (0)	10. I feel anxious (1)	10. I feel anxious (2)	10. I feel anxious (3)	10. I feel anxious (4)	10. I feel anxious (5)
11. I feel hot then cold	11. I feel hot then cold (0)	11. I feel hot then cold (1)	11. I feel hot then cold (2)	11. I feel hot then cold (3)	11. I feel hot then cold (4)	11. I feel hot then cold (5)
12. I have a tremor (shaking)	12. I have a tremor (shaking) (0)	12. I have a tremor (shaking) (1)	12. I have a tremor (shaking) (2)	12. I have a tremor (shaking) (3)	12. I have a tremor (shaking) (4)	12. I have a tremor (shaking) (5)
13. I feel like something bad is about to happen	13. I feel like something bad is about to happen (0)	13. I feel like something bad is about to happen (1)	13. I feel like something bad is about to happen (2)	13. I feel like something bad is about to happen (3)	13. I feel like something bad is about to happen (4)	13. I feel like something bad is about to happen (5)
14. I can't stand feeling this way	14. I can't stand feeling this way (0)	14. I can't stand feeling this way (1)	14. I can't stand feeling this way (2)	14. I can't stand feeling this way (3)	14. I can't stand feeling this way (4)	14. I can't stand feeling this way (5)

OPIOID CRAVING SCALE: Please rate the following questions from 0 to 5. 0 Means strongly disagree and 5 means strongly agree

OPIOID CRAVING SCALE: Please rate the following questions from 0 to 5. 0 Means strongly disagree and 5 means strongly agree
	0	1	2	3	4	5
1. If I had an opioid right now, I would take it.	OPIOID CRAVING SCALE: Please rate the following questions from 0 to 5. 0 Means strongly disagree and 5 means strongly agree: 1. If I had an opioid right now, I would take it. (0)	1. If I had an opioid right now, I would take it. (1)	1. If I had an opioid right now, I would take it. (2)	1. If I had an opioid right now, I would take it. (3)	1. If I had an opioid right now, I would take it. (4)	1. If I had an opioid right now, I would take it. (5)
2. I would not be able to stop myself from taking an opioid right now.	2. I would not be able to stop myself from taking an opioid right now. (0)	2. I would not be able to stop myself from taking an opioid right now. (1)	2. I would not be able to stop myself from taking an opioid right now. (2)	2. I would not be able to stop myself from taking an opioid right now. (3)	2. I would not be able to stop myself from taking an opioid right now. (4)	2. I would not be able to stop myself from taking an opioid right now. (5)
3. I would feel more in control of things if I could take an opioid right now.	3. I would feel more in control of things if I could take an opioid right now. (0)	3. I would feel more in control of things if I could take an opioid right now. (1)	3. I would feel more in control of things if I could take an opioid right now. (2)	3. I would feel more in control of things if I could take an opioid right now. (3)	3. I would feel more in control of things if I could take an opioid right now. (4)	3. I would feel more in control of things if I could take an opioid right now. (5)
4. Taking an opioid right now would make me feel better	4. Taking an opioid right now would make me feel better (0)	4. Taking an opioid right now would make me feel better (1)	4. Taking an opioid right now would make me feel better (2)	4. Taking an opioid right now would make me feel better (3)	4. Taking an opioid right now would make me feel better (4)	4. Taking an opioid right now would make me feel better (5)
5. If I could take an opioid right now, I would feel less restless	5. If I could take an opioid right now, I would feel less restless (0)	5. If I could take an opioid right now, I would feel less restless (1)	5. If I could take an opioid right now, I would feel less restless (2)	5. If I could take an opioid right now, I would feel less restless (3)	5. If I could take an opioid right now, I would feel less restless (4)	5. If I could take an opioid right now, I would feel less restless (5)
6. I am craving an opioid right now.	6. I am craving an opioid right now. (0)	6. I am craving an opioid right now. (1)	6. I am craving an opioid right now. (2)	6. I am craving an opioid right now. (3)	6. I am craving an opioid right now. (4)	6. I am craving an opioid right now. (5)
7. Using an opioid right now would make me feel better	7. Using an opioid right now would make me feel better (0)	7. Using an opioid right now would make me feel better (1)	7. Using an opioid right now would make me feel better (2)	7. Using an opioid right now would make me feel better (3)	7. Using an opioid right now would make me feel better (4)	7. Using an opioid right now would make me feel better (5)

SECTION 17 | NARCOTICS AGREEMENT

PLEASE REVIEW THE INFORMATION CAREFULLY:

1 - I agree to keep appointments and let appropriate staff know if I will be unable to show up as scheduled.

2 - I agree to report my history and my symptoms honestly to BUPE.ME physicians, nurses, and counselors. I also agree to inform BUPE.ME staff of all other physicians and dentists whom I am seeing; of all prescription and non-prescription drugs I am taking; of any alcohol or street drugs I have recently been using; and whether I have become pregnant or have developed hepatitis.

3 - I agree to cooperate with witnessed drug testing whenever requested by BUPE.ME staff, to confirm if I have been using any alcohol, prescription drugs, or street drugs.

4 - I have been informed that the drug Suboxone (found in Suboxone, Bunavail, Zubsolv) is a narcotic analgesic, and thus it can produce a 'high'. I know that taking this medication regularly can lead to physical dependence and addiction, and that if I were to abruptly stop taking this medication after a period of regular use, I could experience symptoms of opiate withdrawal.

5 - I have been informed that the Suboxone/naloxone combination medication should be taken as described by BUPE.ME providers and that this medication should never be used intravenously (Injected).

6 - I have been informed that Suboxone/naloxone is a powerful medication and is to be respected, and that supplies of it must be protected from theft or unauthorized use, since persons who want to get high by using it or who want to sell it for profit, may be motivated to steal my prescription of Suboxone/naloxone medication.

7 - I have a means to store, under lock and key, take-home prescription supplies of Suboxone/naloxone medication safely, where it cannot be taken accidentally by children or pets or stolen by unauthorized users. I further understand that if one dose of this medication is mistakenly ingested by a child, it could lead to death. I agree that if my Suboxone/naloxone is swallowed by anyone besides me, I will call 911 immediately.

We strongly encourage you to keep Narcan in your home at all times. Narcan is a nasal spray that can treat opioid overdose in an emergency situation. it’s readily available at your local pharmacy. Ask your pharmacist on how to use the medication and share this information with your family and / or significant others.

8 - I agree that if my BUPE.ME provider recommends that my home supply of Suboxone/naloxone medication should be kept in the care of a responsible member of my family or another third party, I will abide by such recommendations.

9 - I will be careful with my prescription of Suboxone/naloxone medication and agree that I have been informed that if I report that my prescription has been lost or stolen, that my provider will not be requested or expected to provide me with a make-up prescription. This means that if I run out of my medication it could result in my experiencing symptoms of opiate withdrawal. Also, I agree that if there has been a theft of my medications, I will report this to the police and will provide a copy of the police report to BUPE.ME.

10 -I agree to submit to all prescription medication counts requested by BUPE.ME provider so that remaining supplies can be accounted for by BUPE.ME.

11 - I agree to take my Suboxone/naloxone medication as prescribed, to not skip doses, and that I will not adjust the dose without talking with my BUPE.ME provider about this so that changes in orders can be properly communicated by BUPE.ME to my pharmacy.

12 - I agree that I will not drive a motor vehicle or use power tools or other dangerous machinery during my first days of taking Suboxone/naloxone medication, to make sure that I can tolerate taking it without becoming sleepy or clumsy as a side-effect of taking it.

13 - I understand Suboxone/naloxone medication assisted treatment is just one of several types of treatments for opioid dependency; others including Methadone Treatment, in-patient treatment, and other rehab programs. I have chosen Suboxone/naloxone medication as my choice of treatment after careful consideration.

14 - I have been informed that it can be dangerous to mix Suboxone/naloxone with alcohol or another sedative drug such as Valium, Ativan, Xanax, Klonopin or any other benzodiazepine drug--so dangerous that it could result in accidental overdose, over-sedation, coma, or death. I agree to use no alcoholic beverages and to take no sedative drugs at any time while being treated with Suboxone/naloxone. I have been informed that my BUPE.ME doctor will almost certainly discontinue my Suboxone treatment with Suboxone/naloxone medication if I violate this agreement.

15 - I am not pregnant and will not attempt to become pregnant. If a female, I will not have unprotected sex while I am taking Suboxone/naloxone medication, because of the unknown safety of Suboxone during pregnancy. I have been informed that my BUPE.ME doctor will almost certainly discontinue my Suboxone/naloxone medication treatment if I become pregnant.

16 - I want to be in recovery from addiction to all drugs, and I have been informed that any active addiction to other drugs besides heroin and other opiates must be treated by counseling and other methods. I have been informed that Suboxone (found in Suboxone, Bunavail and Zubsolv) is a treatment designed to treat opiate dependence, not addiction to other classes of drugs.

17 - I agree, with medication assisted treatment of addiction with Suboxone/naloxone medication, to remain compliant in the BUPE.ME program, BUPE.ME expects me to participate in a regular program of counseling i.e.: one on one counseling, group counseling, or support group counseling. 18 – I agree and understand that counseling, combined with the BUPE.ME treatment program, has the best results while I am pursuing my recovery and could prevent relapse and or death.

19 - I agree to participate in a regular program of peer/self-help while being treated with Suboxone/naloxone. An appropriate peer/self-help program could include, but is not limited to, the following: a 12-step program (either Alcoholics Anonymous or Narcotics Anonymous), SMART recovery, a church-based group (e.g. Celebrate Recovery), an online/virtual recovery support community, synchronous or asynchronous telemedicine-based counseling and/or therapy and in-office individual or group counseling and/or therapy.

20 - I agree that it is usually best to let my loved ones know about my medication assisted treatment. I understand that hiding treatment can cause problems in relationships and further perpetuate the cycles of deception and lying that must be broken to achieve meaningful recovery.

21 - I agree that using a pharmacy that can integrate the means to both prevent medication diversion and effect a more compliant toxicology program is best for myself as an individual patient.

22 - I agree to grant Absolute Immunity to BUPE.ME it’s staff, personnel, and all associated persons. This means that, no matter what the circumstances or outcomes, neither myself nor anyone associated with me, including family members, can ever sue or seek damages from BUPE.ME or its associates.

23 - I indemnify, release and hold harmless, and release of all liability BUPE.ME it’s staff, personnel, and all associated persons from any and all outcomes that may arise from my addiction, the treatment of my addiction, or any behaviors or actions that I may take.

24 - I agree to always report accurately the amount of medication I have remaining whenever a medication count request is sent. I understand that falsifying, ignoring or not responding to medication count requests, regardless of the reason, constitutes non-compliance on my part and jeopardizes my standing in the program.

25 - I agree to always submit images for a medication count request that comply to the following:

A) The medication imaged is only made up of my medication from my most recent prescription and that I will not include any leftovers from previous prescriptions or another person’s medication;

B) The medication is laid out appropriately in such a way that all medication can be accurately counted in an expeditious manner;

C) The image(s) submitted will always be taken on either the day the medication request is sent or up to 72 hours later. Any images from other times are not acceptable;

D) The medication must be emptied from all open boxes. If I have an unopened box, I must photograph all sides of the box to prove it has not been opened;

E) If I have a form of the medication that is not in loose pill form (either film or single blister packs), I must take pictures of both the front and back of all my medication to prove that the packaging has not been opened and re-closed. I understand that falsifying, ignoring or not responding to medication count requests (regardless of the reason) constitutes non-compliance on my part and jeopardizes my standing in the program.

26 - I understand that BUPE.ME will check the various Prescription Drug Monitoring Programs or similar resources to verify the accuracy in my medication count.

27 - I will always provide a drug test sample, whether Urine sample, urine or hair, that is only taken by myself or from myself. I understand that if I do not follow this program requirement that I risk my spot in the program.

28 - I will always report the correct date on which I took my drug test. This includes when asked in communication with BUPE.ME providers and staff and on the toxicology submission form that I must complete after mailing a test. I understand that if I do not do the above requirements that I could risk my spot in the program.

29 - I understand that if my medication counts or toxicology tests generates an unexpected result that my BUPE.ME provider(s) might change my treatment plan. Any changes will be at the sole discretion of my provider(s). These changes include, but are not be limited to, the following: new requirements on how frequently I interact with BUPE.ME patient phone app; new counseling/therapy requirements; limiting the number of days-worth of medication I am allowed to pick-up at a single time; increases in quantity and frequency of medication counts and/or toxicology tests, including the possibility of using urine and hair testing as alternatives to Urine sample; new requirements to conduct medication counts and toxicology tests via synchronous or asynchronous video; new requirements to come to the Charlotte home-office to conduct medication counts; toxicology tests and/or discuss my status in the program; and even referral out of the program to a more intensive form of treatment.

30-The majority of encounters with the Providers in this Program are GROUP ENCOUNTERS. This concept of GROUP ENCOUNTERS applies to both the Counseling and the Medical Encounters. If you are in need or wish to attend a program with more of a one on one style of treatment, we support and encourage you in your search for a Program that more fits your needs.

31 - I Agree to grant BUPE.ME it's staff and Providers Absolute Immunity

32 - I Agree to grant BUPE.ME it's staff and Providers indemnification and release and hold Harmless

33 - No New Patient will be allowed into the Practice without agreeing to each and every aspect of the Narcotics Agreement

34 - No Established Patient will be allowed to remain in the Practice without re-agreeing to the Narcotics Agreement every 20 days on average. The purpose of the Narcotics Agreement is to document an understanding of critically important information between the Patient and the Providers of Medical Care of such documentation, as a means of facilitating care, is meant to improve communication of important messaging between Patients and Providers BUPE.ME Patients agree to the following statements during our online registration process. This information is documented, managed and controlled in our EMR

35 - We are providing Buprenorphine, a controlled substance, through Telemedicine. For this reason we require that you pick up your medication in person at the pharmacy. We require that no one picks up the medication on your behalf. By signing this document, you agree to pick up the medication yourself at your pharmacy.

36- I agree to remain in Compliance with all aspects of this Program including this Narcotics Agreement, the Pill Count and Drug Screening Policies, the Counseling Policy, the mandatory Weekly Meetings and my financial responsibility. While I understand it is never the intent of this Program nor its staff to deny or withhold medication, I am aware that my actions of non-compliance could result in such a delay. I accept the responsibility for my actions. A pattern of consistent non-compliance may result in removal from the program

37 - While under the care of bupe.me , I understand that under no circumstances I can take an opioid product from any other provider without contacting bupe.me first. Furthermore, I understand that I cannot get a prescription from another provider for a buprenorphine product. If I violate this rule, I can be terminated from the program.

PLEASE REVIEW THE INFORMATION CAREFULLY: 1 - I agree to keep appointments and let appropriate staff know if I will be unable to show up as scheduled. 2 - I agree to report my history and my symptoms honestly to BUPE.ME physicians, nurses, and counselors. I also agree to inform BUPE.ME staff of all other physicians and dentists whom I am seeing; of all prescription and non-prescription drugs I am taking; of any alcohol or street drugs I have recently been using; and whether I have become pregnant or have developed hepatitis. 3 - I agree to cooperate with witnessed drug testing whenever requested by BUPE.ME staff, to confirm if I have been using any alcohol, prescription drugs, or street drugs. 4 - I have been informed that the drug Suboxone (found in Suboxone, Bunavail, Zubsolv) is a narcotic analgesic, and thus it can produce a 'high'. I know that taking this medication regularly can lead to physical dependence and addiction, and that if I were to abruptly stop taking this medication after a period of regular use, I could experience symptoms of opiate withdrawal. 5 - I have been informed that the Suboxone/naloxone combination medication should be taken as described by BUPE.ME providers and that this medication should never be used intravenously (Injected). 6 - I have been informed that Suboxone/naloxone is a powerful medication and is to be respected, and that supplies of it must be protected from theft or unauthorized use, since persons who want to get high by using it or who want to sell it for profit, may be motivated to steal my prescription of Suboxone/naloxone medication. 7 - I have a means to store, under lock and key, take-home prescription supplies of Suboxone/naloxone medication safely, where it cannot be taken accidentally by children or pets or stolen by unauthorized users. I further understand that if one dose of this medication is mistakenly ingested by a child, it could lead to death. I agree that if my Suboxone/naloxone is swallowed by anyone besides me, I will call 911 immediately. We strongly encourage you to keep Narcan in your home at all times. Narcan is a nasal spray that can treat opioid overdose in an emergency situation. it’s readily available at your local pharmacy. Ask your pharmacist on how to use the medication and share this information with your family and / or significant others. 8 - I agree that if my BUPE.ME provider recommends that my home supply of Suboxone/naloxone medication should be kept in the care of a responsible member of my family or another third party, I will abide by such recommendations. 9 - I will be careful with my prescription of Suboxone/naloxone medication and agree that I have been informed that if I report that my prescription has been lost or stolen, that my provider will not be requested or expected to provide me with a make-up prescription. This means that if I run out of my medication it could result in my experiencing symptoms of opiate withdrawal. Also, I agree that if there has been a theft of my medications, I will report this to the police and will provide a copy of the police report to BUPE.ME. 10 -I agree to submit to all prescription medication counts requested by BUPE.ME provider so that remaining supplies can be accounted for by BUPE.ME. 11 - I agree to take my Suboxone/naloxone medication as prescribed, to not skip doses, and that I will not adjust the dose without talking with my BUPE.ME provider about this so that changes in orders can be properly communicated by BUPE.ME to my pharmacy. 12 - I agree that I will not drive a motor vehicle or use power tools or other dangerous machinery during my first days of taking Suboxone/naloxone medication, to make sure that I can tolerate taking it without becoming sleepy or clumsy as a side-effect of taking it. 13 - I understand Suboxone/naloxone medication assisted treatment is just one of several types of treatments for opioid dependency; others including Methadone Treatment, in-patient treatment, and other rehab programs. I have chosen Suboxone/naloxone medication as my choice of treatment after careful consideration. 14 - I have been informed that it can be dangerous to mix Suboxone/naloxone with alcohol or another sedative drug such as Valium, Ativan, Xanax, Klonopin or any other benzodiazepine drug--so dangerous that it could result in accidental overdose, over-sedation, coma, or death. I agree to use no alcoholic beverages and to take no sedative drugs at any time while being treated with Suboxone/naloxone. I have been informed that my BUPE.ME doctor will almost certainly discontinue my Suboxone treatment with Suboxone/naloxone medication if I violate this agreement. 15 - I am not pregnant and will not attempt to become pregnant. If a female, I will not have unprotected sex while I am taking Suboxone/naloxone medication, because of the unknown safety of Suboxone during pregnancy. I have been informed that my BUPE.ME doctor will almost certainly discontinue my Suboxone/naloxone medication treatment if I become pregnant. 16 - I want to be in recovery from addiction to all drugs, and I have been informed that any active addiction to other drugs besides heroin and other opiates must be treated by counseling and other methods. I have been informed that Suboxone (found in Suboxone, Bunavail and Zubsolv) is a treatment designed to treat opiate dependence, not addiction to other classes of drugs. 17 - I agree, with medication assisted treatment of addiction with Suboxone/naloxone medication, to remain compliant in the BUPE.ME program, BUPE.ME expects me to participate in a regular program of counseling i.e.: one on one counseling, group counseling, or support group counseling. 18 – I agree and understand that counseling, combined with the BUPE.ME treatment program, has the best results while I am pursuing my recovery and could prevent relapse and or death. 19 - I agree to participate in a regular program of peer/self-help while being treated with Suboxone/naloxone. An appropriate peer/self-help program could include, but is not limited to, the following: a 12-step program (either Alcoholics Anonymous or Narcotics Anonymous), SMART recovery, a church-based group (e.g. Celebrate Recovery), an online/virtual recovery support community, synchronous or asynchronous telemedicine-based counseling and/or therapy and in-office individual or group counseling and/or therapy. 20 - I agree that it is usually best to let my loved ones know about my medication assisted treatment. I understand that hiding treatment can cause problems in relationships and further perpetuate the cycles of deception and lying that must be broken to achieve meaningful recovery. 21 - I agree that using a pharmacy that can integrate the means to both prevent medication diversion and effect a more compliant toxicology program is best for myself as an individual patient. 22 - I agree to grant Absolute Immunity to BUPE.ME it’s staff, personnel, and all associated persons. This means that, no matter what the circumstances or outcomes, neither myself nor anyone associated with me, including family members, can ever sue or seek damages from BUPE.ME or its associates. 23 - I indemnify, release and hold harmless, and release of all liability BUPE.ME it’s staff, personnel, and all associated persons from any and all outcomes that may arise from my addiction, the treatment of my addiction, or any behaviors or actions that I may take. 24 - I agree to always report accurately the amount of medication I have remaining whenever a medication count request is sent. I understand that falsifying, ignoring or not responding to medication count requests, regardless of the reason, constitutes non-compliance on my part and jeopardizes my standing in the program. 25 - I agree to always submit images for a medication count request that comply to the following: A) The medication imaged is only made up of my medication from my most recent prescription and that I will not include any leftovers from previous prescriptions or another person’s medication; B) The medication is laid out appropriately in such a way that all medication can be accurately counted in an expeditious manner; C) The image(s) submitted will always be taken on either the day the medication request is sent or up to 72 hours later. Any images from other times are not acceptable; D) The medication must be emptied from all open boxes. If I have an unopened box, I must photograph all sides of the box to prove it has not been opened; E) If I have a form of the medication that is not in loose pill form (either film or single blister packs), I must take pictures of both the front and back of all my medication to prove that the packaging has not been opened and re-closed. I understand that falsifying, ignoring or not responding to medication count requests (regardless of the reason) constitutes non-compliance on my part and jeopardizes my standing in the program. 26 - I understand that BUPE.ME will check the various Prescription Drug Monitoring Programs or similar resources to verify the accuracy in my medication count. 27 - I will always provide a drug test sample, whether Urine sample, urine or hair, that is only taken by myself or from myself. I understand that if I do not follow this program requirement that I risk my spot in the program. 28 - I will always report the correct date on which I took my drug test. This includes when asked in communication with BUPE.ME providers and staff and on the toxicology submission form that I must complete after mailing a test. I understand that if I do not do the above requirements that I could risk my spot in the program. 29 - I understand that if my medication counts or toxicology tests generates an unexpected result that my BUPE.ME provider(s) might change my treatment plan. Any changes will be at the sole discretion of my provider(s). These changes include, but are not be limited to, the following: new requirements on how frequently I interact with BUPE.ME patient phone app; new counseling/therapy requirements; limiting the number of days-worth of medication I am allowed to pick-up at a single time; increases in quantity and frequency of medication counts and/or toxicology tests, including the possibility of using urine and hair testing as alternatives to Urine sample; new requirements to conduct medication counts and toxicology tests via synchronous or asynchronous video; new requirements to come to the Charlotte home-office to conduct medication counts; toxicology tests and/or discuss my status in the program; and even referral out of the program to a more intensive form of treatment. 30-The majority of encounters with the Providers in this Program are GROUP ENCOUNTERS. This concept of GROUP ENCOUNTERS applies to both the Counseling and the Medical Encounters. If you are in need or wish to attend a program with more of a one on one style of treatment, we support and encourage you in your search for a Program that more fits your needs. 31 - I Agree to grant BUPE.ME it's staff and Providers Absolute Immunity 32 - I Agree to grant BUPE.ME it's staff and Providers indemnification and release and hold Harmless 33 - No New Patient will be allowed into the Practice without agreeing to each and every aspect of the Narcotics Agreement 34 - No Established Patient will be allowed to remain in the Practice without re-agreeing to the Narcotics Agreement every 20 days on average. The purpose of the Narcotics Agreement is to document an understanding of critically important information between the Patient and the Providers of Medical Care of such documentation, as a means of facilitating care, is meant to improve communication of important messaging between Patients and Providers BUPE.ME Patients agree to the following statements during our online registration process. This information is documented, managed and controlled in our EMR 35 - We are providing Buprenorphine, a controlled substance, through Telemedicine. For this reason we require that you pick up your medication in person at the pharmacy. We require that no one picks up the medication on your behalf. By signing this document, you agree to pick up the medication yourself at your pharmacy. 36- I agree to remain in Compliance with all aspects of this Program including this Narcotics Agreement, the Pill Count and Drug Screening Policies, the Counseling Policy, the mandatory Weekly Meetings and my financial responsibility. While I understand it is never the intent of this Program nor its staff to deny or withhold medication, I am aware that my actions of non-compliance could result in such a delay. I accept the responsibility for my actions. A pattern of consistent non-compliance may result in removal from the program 37 - While under the care of bupe.me , I understand that under no circumstances I can take an opioid product from any other provider without contacting bupe.me first. Furthermore, I understand that I cannot get a prescription from another provider for a buprenorphine product. If I violate this rule, I can be terminated from the program. *

I have read and agree to the BUPE.ME Narcotics Agreement.

SECTION 18 | INFORMED CONSENT

PLEASE REVIEW THE INFORMATION CAREFULLY:

1 - Suboxone is a medication approved by the Food and Drug Administration (FDA) for treatment of people with opioid dependence. Suboxone can be used for detoxification or for maintenance therapy. Maintenance therapy can continue as long as medically necessary.

2 - Suboxone itself is an opioid, but it is not as strong an opioid as heroin or morphine. Suboxone treatment can result in physical dependence of the opiate type. Suboxone withdrawal is generally less intense than with heroin or methadone. If Suboxone is suddenly discontinued, some patients have no withdrawal symptoms; others have symptoms such as muscle aches, stomach cramps, or diarrhea lasting several days. To minimize the possibility of opiate withdrawal, Suboxone should be discontinued gradually, usually over several weeks or more.

3 - If you are dependent on opiates, you should be in as much withdrawal as possible when you take the first dose of Suboxone. It you are not in withdrawal, Suboxone may cause significant opioid withdrawal. Some patients find that it takes several days to get used to the transition from the opioid they had been using to Suboxone. During that time, any use of other opioids may cause an increase in symptoms. After you become stabilized on Suboxone, it is expected that other opioids will have less effect.

4 - Attempts to override the Suboxone by taking more opioids could result in an opioid overdose.

5 - You should not take any other medication without discussing it with the medical staff first. Combining Suboxone with alcohol or some other medications may also be hazardous. The combination of Suboxone with benzodiazipine medication such as Valium, Xanax, Klonopin, Librium, and Ativan has resulted in deaths.

6 - The form of Suboxone (Suboxone) you will be taking is a combination of Suboxone with a short-acting opiate blocker (Naloxone). If the Suboxone tablet were dissolved and injected by someone taking heroin or another strong opioid, it could cause severe opiate withdrawal.

7 - Suboxone tables must be held under the tongue until they dissolve completely. Suboxone is then absorbed over the next 30 to 120 minutes from the tissue under the tongue. Suboxone will not be absorbed from the stomach if it is swallowed.

8 - Alternatives to Suboxone: Some hospitals that have specialized drug abuse treatment units can provide detoxification and intensive counseling for drug abuse. Some outpatient drug abuse treatment services also provide individual and group therapy, which may emphasize treatment that does not include maintenance on Suboxone or other opiate like medications. Other forms of opioid maintenance therapy include methadone maintenance. Some opioid treatment programs use naltrexone, a medication that blocks the effects of opioids, but has no opioid effects of its own.

9 - There are some very important things that you need to know about the medication you are taking called Buprenorphine. In fact, we would like to discuss three things with you right now and then ask you some questions to be sure that you understand. The four items for discussion are:

1). Being sure that you are not having cravings as you get started with us.

2). Knowing that Buprenorphine has side effects and can interact with other medications and could hurt you.

3). Always use the lowest possible dosage.

4). If you return to your old opioids, your tolerance is lower and you may die.

Let’s begin by talking about making sure that you are not having any cravings. There is some scientific evidence that the dosage of 16 mgms a day might be safer as a starting dosage to be sure that you are not having any dangerous cravings. But, in our opinion, 16 mgms a day is a very high dosage. We strongly encourage you to wean down slowly, over the next few months, to 8 mgms and even lower if possible.

If you are having cravings at 16 mgms a day and feel that you need a higher dosage, this is not the right program for you.

Secondly, all medications have side effects. And all medications can interact with other medications. Again, we don’t want you to wean down too fast and experience cravings and be tempted to abuse your old opioids, but if you are taking other medications, it is important that you seriously try to wean down below 16 mgms a day.

Thirdly, and we want to strongly emphasize this point - use the lowest possible dosage of Buprenorphine. You don’t want cravings. And you do not want the withdrawal to return. But you do want as few of side effects as possible. Especially if you are taking other medications. But know this, the lower your dosage, the less protection you will have if you do use your old opioids again. And that’s one of the most important things for you to know. As you wean down, and if you abuse the old opioids again, you may die.

And lastly, and again we want to make this point as strongly as we can, as you wean below 16 mgms a day, and if you abuse your old opioids again, your tolerance is lower, and you may die.

PLEASE REVIEW THE INFORMATION CAREFULLY: 1 - Suboxone is a medication approved by the Food and Drug Administration (FDA) for treatment of people with opioid dependence. Suboxone can be used for detoxification or for maintenance therapy. Maintenance therapy can continue as long as medically necessary. 2 - Suboxone itself is an opioid, but it is not as strong an opioid as heroin or morphine. Suboxone treatment can result in physical dependence of the opiate type. Suboxone withdrawal is generally less intense than with heroin or methadone. If Suboxone is suddenly discontinued, some patients have no withdrawal symptoms; others have symptoms such as muscle aches, stomach cramps, or diarrhea lasting several days. To minimize the possibility of opiate withdrawal, Suboxone should be discontinued gradually, usually over several weeks or more. 3 - If you are dependent on opiates, you should be in as much withdrawal as possible when you take the first dose of Suboxone. It you are not in withdrawal, Suboxone may cause significant opioid withdrawal. Some patients find that it takes several days to get used to the transition from the opioid they had been using to Suboxone. During that time, any use of other opioids may cause an increase in symptoms. After you become stabilized on Suboxone, it is expected that other opioids will have less effect. 4 - Attempts to override the Suboxone by taking more opioids could result in an opioid overdose. 5 - You should not take any other medication without discussing it with the medical staff first. Combining Suboxone with alcohol or some other medications may also be hazardous. The combination of Suboxone with benzodiazipine medication such as Valium, Xanax, Klonopin, Librium, and Ativan has resulted in deaths. 6 - The form of Suboxone (Suboxone) you will be taking is a combination of Suboxone with a short-acting opiate blocker (Naloxone). If the Suboxone tablet were dissolved and injected by someone taking heroin or another strong opioid, it could cause severe opiate withdrawal. 7 - Suboxone tables must be held under the tongue until they dissolve completely. Suboxone is then absorbed over the next 30 to 120 minutes from the tissue under the tongue. Suboxone will not be absorbed from the stomach if it is swallowed. 8 - Alternatives to Suboxone: Some hospitals that have specialized drug abuse treatment units can provide detoxification and intensive counseling for drug abuse. Some outpatient drug abuse treatment services also provide individual and group therapy, which may emphasize treatment that does not include maintenance on Suboxone or other opiate like medications. Other forms of opioid maintenance therapy include methadone maintenance. Some opioid treatment programs use naltrexone, a medication that blocks the effects of opioids, but has no opioid effects of its own. 9 - There are some very important things that you need to know about the medication you are taking called Buprenorphine. In fact, we would like to discuss three things with you right now and then ask you some questions to be sure that you understand. The four items for discussion are: 1). Being sure that you are not having cravings as you get started with us. 2). Knowing that Buprenorphine has side effects and can interact with other medications and could hurt you. 3). Always use the lowest possible dosage. 4). If you return to your old opioids, your tolerance is lower and you may die. Let’s begin by talking about making sure that you are not having any cravings. There is some scientific evidence that the dosage of 16 mgms a day might be safer as a starting dosage to be sure that you are not having any dangerous cravings. But, in our opinion, 16 mgms a day is a very high dosage. We strongly encourage you to wean down slowly, over the next few months, to 8 mgms and even lower if possible. If you are having cravings at 16 mgms a day and feel that you need a higher dosage, this is not the right program for you. Secondly, all medications have side effects. And all medications can interact with other medications. Again, we don’t want you to wean down too fast and experience cravings and be tempted to abuse your old opioids, but if you are taking other medications, it is important that you seriously try to wean down below 16 mgms a day. Thirdly, and we want to strongly emphasize this point - use the lowest possible dosage of Buprenorphine. You don’t want cravings. And you do not want the withdrawal to return. But you do want as few of side effects as possible. Especially if you are taking other medications. But know this, the lower your dosage, the less protection you will have if you do use your old opioids again. And that’s one of the most important things for you to know. As you wean down, and if you abuse the old opioids again, you may die. And lastly, and again we want to make this point as strongly as we can, as you wean below 16 mgms a day, and if you abuse your old opioids again, your tolerance is lower, and you may die.*

I have read and agree to the BUPE.ME Informed Consent.

Additional Informed Consent for Individuals age 60 and above

All medications have the potential for a side effect. There is no treatment with a medicine that doesn’t carry some risk. Hopefully, the benefit of the medication outweighs the risk. But it is our responsibility to do our best to explain the risk to you and in a way that you can understand.

We understand that without the Buprenorphine that it is difficult for you to live a normal life. We understand that you are choosing to take Buprenorphine on a regular basis in order to stabilize yourself and avoid the terrible symptoms of withdrawal. But we want to be sure that you are making a fully informed decision.

Buprenorphine, the active drug in Suboxone, Zubsolv, Subutex, and the generics, is classified as an opioid. And as an opioid, there is a risk to your body. This risk could be to practically any part of your body. But the risk could be greater to such organs as your heart, lungs, or liver. There is always the risk that a side effect can be severe, even life threatening. To put it into plain language, there is a risk that you could stop breathing or that your heart could stop beating. And we need to be sure that we have explained this to you.

And as we get older, the chance of a side effect increases. And this is something that you need to be aware of. Not only does the risk of a side effect increase as we age, but also the risk of a side effect increases as a person takes other medication. Risks are also increased by smoking tobacco products. And finally, the risk of a side effect increases as the dosage of the medication is increased. Higher dosages of a medication are associated with a higher risk of a side effect.

Let’s review what we have said so far:

All medications have the risk of a side effect
Hopefully, the good effects of a medication outweighs the side effects
The risk of a side effect increases as we age
The risk of a side effect increases as we take additional medications
All risks is increased by smoking tobacco.
The risk of a side effect increases as we increase the daily dosage of a medication

The final decision to take Buprenorphine is up to you. We have discussed the risk of side effects. And if you choose to take Buprenorphine, understand that we will support your decision. But understand that all risk is upon you. If you have a side effect, if your heart, lungs, breathing, liver, anything about your body is harmed by the Buprenorphine, the risk and the responsibility for the decision is upon you. We are here to help. But the risk of treatment with Buprenorphine is upon you.

Finally, we recommend an annual physical evaluation by your primary care provider.

I understand that all medications have risk. I understand that this risk increases as we age, as we take additional medications, and as we take higher dosage of a medication. In my circumstances, the good effects of Buprenorphine are greater than the risk. It is my choice to take Buprenorphine. I release this organization and my Provider from any responsibility for side effects, harm, or even death that may occur due to the Buprenorphine.

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Additional Informed Consent for Individuals age 60 and above All medications have the potential for a side effect. There is no treatment with a medicine that doesn’t carry some risk. Hopefully, the benefit of the medication outweighs the risk. But it is our responsibility to do our best to explain the risk to you and in a way that you can understand. We understand that without the Buprenorphine that it is difficult for you to live a normal life. We understand that you are choosing to take Buprenorphine on a regular basis in order to stabilize yourself and avoid the terrible symptoms of withdrawal. But we want to be sure that you are making a fully informed decision. Buprenorphine, the active drug in Suboxone, Zubsolv, Subutex, and the generics, is classified as an opioid. And as an opioid, there is a risk to your body. This risk could be to practically any part of your body. But the risk could be greater to such organs as your heart, lungs, or liver. There is always the risk that a side effect can be severe, even life threatening. To put it into plain language, there is a risk that you could stop breathing or that your heart could stop beating. And we need to be sure that we have explained this to you. And as we get older, the chance of a side effect increases. And this is something that you need to be aware of. Not only does the risk of a side effect increase as we age, but also the risk of a side effect increases as a person takes other medication. Risks are also increased by smoking tobacco products. And finally, the risk of a side effect increases as the dosage of the medication is increased. Higher dosages of a medication are associated with a higher risk of a side effect. Let’s review what we have said so far: • All medications have the risk of a side effect • Hopefully, the good effects of a medication outweighs the side effects • The risk of a side effect increases as we age • The risk of a side effect increases as we take additional medications • All risks is increased by smoking tobacco. • The risk of a side effect increases as we increase the daily dosage of a medication The final decision to take Buprenorphine is up to you. We have discussed the risk of side effects. And if you choose to take Buprenorphine, understand that we will support your decision. But understand that all risk is upon you. If you have a side effect, if your heart, lungs, breathing, liver, anything about your body is harmed by the Buprenorphine, the risk and the responsibility for the decision is upon you. We are here to help. But the risk of treatment with Buprenorphine is upon you. Finally, we recommend an annual physical evaluation by your primary care provider. I understand that all medications have risk. I understand that this risk increases as we age, as we take additional medications, and as we take higher dosage of a medication. In my circumstances, the good effects of Buprenorphine are greater than the risk. It is my choice to take Buprenorphine. I release this organization and my Provider from any responsibility for side effects, harm, or even death that may occur due to the Buprenorphine. *

I Agree

SECTION 19 | ELECTRONIC CODE OF FEDERAL REGULATIONS

Your right to privacy is protected by a very powerful Federal Law. If you would like to review this law, click on the following link:

MODEL POLICY FOR THE APPROPRIATE USE OF TELEMEDICINE TECHNOLOGIES IN THE PRACTICE OF MEDICINE

We are always available to discuss the details of this law with you.

MODEL POLICY FOR THE APPROPRIATE USE OF TELEMEDICINE TECHNOLOGIES IN THE PRACTICE OF MEDICINE Report of the State Medical Boards’ Appropriate Regulation of Telemedicine (SMART) Workgroup Adopted as policy by the Federation of State Medical Boards in April 2014 INTRODUCTION The Federation of State Medical Boards (FSMB) Chair, Jon V. Thomas, MD, MBA, appointed the State Medical Boards’ Appropriate Regulation of Telemedicine (SMART) Workgroup to review the “Model Guidelines for the Appropriate Use of the Internet in Medical Practice” (HOD 2002)1 and other existing FSMB policies on telemedicine and to offer recommendations to state medical and osteopathic boards (hereinafter referred to as “medical boards” and/or “boards”) based on a thorough review of recent advances in technology and the appropriate balance between enabling access to care while ensuring patient safety. The Workgroup was charged with guiding the development of model guidelines for use by state medical boards in evaluating the appropriateness of care as related to the use of telemedicine, or the practice of medicine using electronic communication, information technology or other means, between a physician in one location and a patient in another location with or without an intervening health care provider. This new policy document provides guidance to state medical boards for regulating the use of telemedicine technologies in the practice of medicine and educates licensees as to the appropriate standards of care in the delivery of medical services directly to patients2 via telemedicine technologies. It is the intent of the SMART Workgroup to offer a model policy for use by state medical boards in order to remove regulatory barriers to widespread appropriate adoption of telemedicine technologies for delivering care while ensuring the public health and safety. In developing the guidelines that follow, the Workgroup conducted a comprehensive review of telemedicine technologies currently in use and proposed/recommended standards of care, as well as identified and considered existing standards of care applicable to telemedicine developed and implemented by several state medical boards. Section One. Preamble The advancements and continued development of medical and communications technology have had a profound impact on the practice of medicine and offer opportunities for improving the delivery and accessibility of health care, particularly in the area of telemedicine, which is the practice of medicine using electronic communication, information technology or other means of interaction between a licensee in one location and a patient in another location with or without an intervening healthcare provider.3 However, state medical boards, in fulfilling their duty to protect the public, face complex regulatory challenges and patient safety concerns in adapting regulations and standards historically intended for the in-person provision of medical care to new delivery models involving telemedicine technologies, including but not limited to: 1) determining when a physician-patient relationship is established; 2) assuring privacy of patient data; 3) guaranteeing proper evaluation and treatment of the patient; and 4) limiting the prescribing and dispensing of certain medications. The [Name of Board] recognizes that using telemedicine technologies in the delivery of medical services offers potential benefits in the provision of medical care. The appropriate application of these technologies can enhance medical care by facilitating communication with physicians and their patients or other health care providers, including prescribing medication, obtaining laboratory results, scheduling appointments, monitoring chronic conditions, providing health care information, and clarifying medical advice.4 These guidelines should not be construed to alter the scope of practice of any health care provider or authorize the delivery of health care services in a setting, or in a manner, not otherwise authorized by law. In fact, these guidelines support a consistent standard of care and scope of practice notwithstanding the delivery tool or business method in enabling Physician-to-Patient communications. For clarity, a physician using telemedicine technologies in the provision of medical services to a patient (whether existing or new) must take appropriate steps to establish the physician-patient relationship and conduct all appropriate evaluations and history of the patient consistent with traditional standards of care for the particular patient presentation. As such, some situations and patient presentations are appropriate for the utilization of telemedicine technologies as a component of, or in lieu of, in-person provision of medical care, while others are not.5 The Board has developed these guidelines to educate licensees as to the appropriate use of telemedicine technologies in the practice of medicine. The [Name of Board] is committed to assuring patient access to the convenience and benefits afforded by telemedicine technologies, while promoting the responsible practice of medicine by physicians. It is the expectation of the Board that physicians who provide medical care, electronically or otherwise, maintain the highest degree of professionalism and should: • Place the welfare of patients first; • Maintain acceptable and appropriate standards of practice; • Adhere to recognized ethical codes governing the medical profession; • Properly supervise non-physician clinicians; and • Protect patient confidentiality. Section Two. Establishing the Physician-Patient Relationship The health and well-being of patients depends upon a collaborative effort between the physician and patient.6 The relationship between the physician and patient is complex and is based on the mutual understanding of the shared responsibility for the patient’s health care. Although the Board recognizes that it may be difficult in some circumstances to precisely define the beginning of the physician-patient relationship, particularly when the physician and patient are in separate locations, it tends to begin when an individual with a health-related matter seeks assistance from a physician who may provide assistance. However, the relationship is clearly established when the physician agrees to undertake diagnosis and treatment of the patient, and the patient agrees to be treated, whether or not there has been an encounter in person between the physician (or other appropriately supervised health care practitioner) and patient. The physician-patient relationship is fundamental to the provision of acceptable medical care. It is the expectation of the Board that physicians recognize the obligations, responsibilities, and patient rights associated with establishing and maintaining a physician-patient relationship. A physician is discouraged from rendering medical advice and/or care using telemedicine technologies without (1) fully verifying and authenticating the location and, to the extent possible, identifying the requesting patient; (2) disclosing and validating the provider’s identity and applicable credential(s); and (3) obtaining appropriate consents from requesting patients after disclosures regarding the delivery models and treatment methods or limitations, including any special informed consents regarding the use of telemedicine technologies. An appropriate physician-patient relationship has not been established when the identity of the physician may be unknown to the patient. Where appropriate, a patient must be able to select an identified physician for telemedicine services and not be assigned to a physician at random. Section Three. Definitions For the purpose of these guidelines, the following definitions apply: “Telemedicine” means the practice of medicine using electronic communications, information technology or other means between a licensee in one location, and a patient in another location with or without an intervening healthcare provider. Generally, telemedicine is not an audio-only, telephone conversation, e-mail/instant messaging conversation, or fax. It typically involves the application of secure videoconferencing or store and forward technology to provide or support healthcare delivery by replicating the interaction of a traditional, encounter in person between a provider and a patient.7 “Telemedicine Technologies” means technologies and devices enabling secure electronic communications and information exchange between a licensee in one location and a patient in another location with or without an intervening healthcare provider. MODEL POLICY FOR THE APPROPRIATE USE OF TELEMEDICINE TECHNOLOGIES IN THE PRACTICE OF MEDICINE Section Four. Guidelines for the Appropriate Use of Telemedicine Technologies in Medical Practice The [Name of Board] has adopted the following guidelines for physicians utilizing telemedicine technologies in the delivery of patient care, regardless of an existing physician-patient relationship prior to an encounter: Licensure: A physician must be licensed, or under the jurisdiction, of the medical board of the state where the patient is located. The practice of medicine occurs where the patient is located at the time telemedicine technologies are used. Physicians who treat or prescribe through online services sites are practicing medicine and must possess appropriate licensure in all jurisdictions where patients receive care.8 Establishment of a Physician-Patient Relationship: Where an existing physician-patient relationship is not present, a physician must take appropriate steps to establish a physician-patient relationship consistent with the guidelines identified in Section Two, and, while each circumstance is unique, such physician-patient relationships may be established using telemedicine technologies provided the standard of care is met. Evaluation and Treatment of the Patient: A documented medical evaluation and collection of relevant clinical history commensurate with the presentation of the patient to establish diagnoses and identify underlying conditions and/or contra-indications to the treatment recommended/provided must be obtained prior to providing treatment, including issuing prescriptions, electronically or otherwise. Treatment and consultation recommendations made in an online setting, including issuing a prescription via electronic means, will be held to the same standards of appropriate practice as those in traditional (encounter in person) settings. Treatment, including issuing a prescription based solely on an online questionnaire, does not constitute an acceptable standard of care. Informed Consent: Evidence documenting appropriate patient informed consent for the use of telemedicine technologies must be obtained and maintained. Appropriate informed consent should, as a baseline, include the following terms: • Identification of the patient, the physician and the physician’s credentials; • Types of transmissions permitted using telemedicine technologies (e.g. prescription refills, appointment scheduling, patient education, etc.); • The patient agrees that the physician determines whether or not the condition being diagnosed and/or treated is appropriate for a telemedicine encounter; • Details on security measures taken with the use of telemedicine technologies, such as encrypting data, password protected screen savers and data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures; • Hold harmless clause for information lost due to technical failures; and • Requirement for express patient consent to forward patient-identifiable information to a third party. Continuity of Care: Patients should be able to seek, with relative ease, follow-up care or information from the physician [or physician’s designee] who conducts an encounter using telemedicine technologies. Physicians solely providing services using telemedicine technologies with no existing physician-patient relationship prior to the encounter must make documentation of the encounter using telemedicine technologies easily available to the patient, and subject to the patient’s consent, any identified care provider of the patient immediately after the encounter. Referrals for Emergency Services: An emergency plan is required and must be provided by the physician to the patient when the care provided using telemedicine technologies indicates that a referral to an acute care facility or ER for treatment is necessary for the safety of the patient. The emergency plan should include a formal, written protocol appropriate to the services being rendered via telemedicine technologies. Medical Records: The medical record should include, if applicable, copies of all patient-related electronic communications, including patient-physician communication, prescriptions, laboratory and test results, evaluations and consultations, records of past care, and instructions obtained or produced in connection with the utilization of telemedicine technologies. Informed consents obtained in connection with an encounter involving telemedicine technologies should also be filed in the medical record. The patient record established during the use of telemedicine technologies must be accessible and documented for both the physician and the patient, consistent with all established laws and regulations governing patient healthcare records. Privacy and Security of Patient Records & Exchange of Information: Physicians should meet or exceed applicable federal and state legal requirements of medical/health information privacy, including compliance with the Health Insurance Portability and Accountability Act (HIPAA) and state privacy, confidentiality, security, and medical retention rules. Physicians are referred to “Standards for Privacy of Individually Identifiable Health Information,” issued by the Department of Health and Human Services (HHS).9 Guidance documents are available on the HHS Office for Civil Rights Web site at: www.hhs.gov/ocr/hipaa. Written policies and procedures should be maintained at the same standard as traditional face-to-face encounters for documentation, maintenance, and transmission of the records of the encounter using telemedicine technologies. Such policies and procedures should address (1) privacy, (2) health-care personnel (in addition to the physician addressee) who will process messages, (3) hours of operation, (4) types of transactions that will be permitted electronically, (5) required patient information to be included in the communication, such as patient name, identification number and type of transaction, (6) archival and retrieval, and (7) quality oversight mechanisms. Policies and procedures should be periodically evaluated for currency and be maintained in an accessible and readily available manner for review. Sufficient privacy and security measures must be in place and documented to assure confidentiality and integrity of patient-identifiable information. Transmissions, including patient e-mail, prescriptions, and laboratory MODEL POLICY FOR THE APPROPRIATE USE OF TELEMEDICINE TECHNOLOGIES IN THE PRACTICE OF MEDICINE results must be secure within existing technology (i.e. password protected, encrypted electronic prescriptions, or other reliable authentication techniques). All patient-physician e-mail, as well as other patient-related electronic communications, should be stored and filed in the patient’s medical record, consistent with traditional recordkeeping policies and procedures. Disclosures and Functionality on Online Services Making Available Telemedicine Technologies: Online services used by physicians providing medical services using telemedicine technologies should clearly disclose: • Specific services provided; • Contact information for physician; • Licensure and qualifications of physician(s) and associated physicians; • Fees for services and how payment is to be made; • Financial interests, other than fees charged, in any information, products, or services provided by a physician; • Appropriate uses and limitations of the site, including emergency health situations; • Uses and response times for e-mails, electronic messages and other communications transmitted via telemedicine technologies; • To whom patient health information may be disclosed and for what purpose; • Rights of patients with respect to patient health information; and • Information collected and any passive tracking mechanisms utilized. Online services used by physicians providing medical services using telemedicine technologies should provide patients a clear mechanism to: • Access, supplement and amend patient-provided personal health information; • Provide feedback regarding the site and the quality of information and services; and • Register complaints, including information regarding filing a complaint with the applicable state medical and osteopathic board(s). Online services must have accurate and transparent information about the website owner/operator, location, and contact information, including a domain name that accurately reflects the identity. Advertising or promotion of goods or products from which the physician receives direct remuneration, benefits, or incentives (other than the fees for the medical care services) is prohibited. Notwithstanding, online services may provide links to general health information sites to enhance patient education; however, the physician should not benefit financially from providing such links or from the services or products marketed by such links. When providing links to other sites, physicians should be aware of the implied endorsement of the information, services or products offered from such sites. The maintenance of preferred relationships with any pharmacy is prohibited. Physicians shall not transmit prescriptions to a specific pharmacy, or recommend a pharmacy, in exchange for any type of consideration or benefit form that pharmacy. Prescribing: Telemedicine technologies, where prescribing may be contemplated, must implement measures to uphold patient safety in the absence of traditional physical examination. Such measures should guarantee that the identity of the patient and provider is clearly established and that detailed documentation for the clinical evaluation and resulting prescription is both enforced and independently kept. Measures to assure informed, accurate, and error prevention prescribing practices (e.g. integration with e-Prescription systems) are encouraged. To further assure patient safety in the absence of physical examination, telemedicine technologies should limit medication formularies to ones that are deemed safe by [Name of Board]. Prescribing medications, in-person or via telemedicine, is at the professional discretion of the physician. The indication, appropriateness, and safety considerations for each telemedicine visit prescription must be evaluated by the physician in accordance with current standards of practice and consequently carry the same professional accountability as prescriptions delivered during an encounter in person. However, where such measures are upheld, and the appropriate clinical consideration is carried out and documented, physicians may exercise their judgment and prescribe medications as part of telemedicine encounters. Section Five. Parity of Professional and Ethical Standards Physicians are encouraged to comply with nationally recognized health online service standards and codes of ethics, such as those promulgated by the American Medical Association, American Osteopathic Association, Health Ethics Initiative 2000, Health on the Net and the American Accreditation HealthCare Commission (URAC). There should be parity of ethical and professional standards applied to all aspects of a physician’s practice. A physician’s professional discretion as to the diagnoses, scope of care, or treatment should not be limited or influenced by non-clinical considerations of telemedicine technologies, and physician remuneration or treatment recommendations should not be materially based on the delivery of patient-desired outcomes (i.e. a prescription or referral) or the utilization of telemedicine technologies.*

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SECTION 20 | NOTIFICATIONS AND ALERTS

Text Message and notifications: By checking this box, I agree to receive automated text messages from BUPE.ME with program news and updates to the cell phone number I have provided. I also understand that message and data rates may apply. **

I Agree

SECTION 21 | HIPAA Privacy And Release Authorization Form

Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)

1 Authorization *

I authorize the Medical Treatment Group Bupe.me to use and disclose the protected health information described below:

2 - Effective Period : This authorization for release of information covers the period of healthcare from:**

All past, present, and future periods

Other:

3 - Extent of Authorization*

I authorize the release of my complete health records (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse). I authorize the release of my complete health record with the exception of the following information:

3.1 Release Exceptions*

Mental health records Communicable diseases (including HIV and AIDS) Alcohol/drug abuse treatment

Other:

4 - This medical information may be used by the person authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.*

I Agree

5 - This authorization shall be in force and effect until:*

Rescinded in writing at which time this authorization expires

Other:

6 - I understand that I have the right to revoke this authorization, in writing, at any time .I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim*

I Agree

7 - I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether sign this authorization.**

I Agree

8 - I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.*

I Agree

9 - MEDICAL DISCLAIMER : I understand that the medical record released pursuant to this authorization could contain information concerning drug related conditions, alcoholism, psychological conditions, psychiatric conditions, and/or blood borne infectious disease, which are subject to federal and/or state restrictions on disclosure. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. I hereby affirm that I have read and fully understand the above statements and consent to the disclosure of the medical record for the purpose and extent stated above.*

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SECTION 22 | PATIENT'S SIGNATURE

IMPORTANT: After you click and / or tap on the submit from button, You will be redirected to our payment portal to make a payment for your treatment. Please click / tap the Submit form now. Thank you.

Signature of Patient/Responsible Party Signature: By signing below, I certify all information in this document is true and correct to the best of my knowledge.*

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