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 always keep Narcan in your home. Narcan is a nasal spray that can treat opioid overdose in an emergency, it is 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 understand that BUPE.ME reserves the right to send my prescription medication to a pharmacy of choice and I waive my right to choose a pharmacy. I also understand that BUPE.ME will be sending my prescription medication to one of these pharmacies and the pharmacy will deliver the prescribed medication to the UPS Store closest to your home for pickup. I further understand that no one will know the contents of the package or anything about your personal business and for a marginal fee, the medication can be delivered directly to your home with a signature required.
22 - 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.
23 - 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.
24 - 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.
25 - 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.
26 - 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.
27 - I understand that BUPE.ME will check the various Prescription Drug Monitoring Programs or similar resources to verify the accuracy in my medication count.
28 - 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.
29 - 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.
30 - 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.
31-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.
32 - I Agree to grant Bupe.me, it's staff and Providers Absolute Immunity
33 - I Agree to grant Bupe.me, it's staff and Providers indemnification and release and hold Harmless
34 - No Patient will be allowed to stay in the Practice without agreeing to each and every aspect of the Narcotics Agreement
35 - 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.
36 - 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.
37- 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.
38 -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.