RESTART PATIENT SELF - REGISTRATION MEDICAL FORM 

First of all and upmost, we want to welcome back to bupe.me

IMPORTANT: This form is for restart patients only!

Please fill this form to the best of your knowledge. Fields marked with an* are required.

REMINDER: You need to have a valid and personal (not shared) 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.


Once we are ready to complete your readmission, you will receive a text message with a link for your provider's teleconference meeting. Simply click on the link, allow your camera to use the app and wait for your provider in the virtual room.

SECTION 1 | DEMOGRAPHICS

Patient Name*
Date of Birth*
Gender*
Home Address*
Employment*

SECTION 1A | RESTART QUESTIONS

Why did you decide to come back to this program? You can select more than one option. Feel free to tell us more. *
WHEN YOU LEFT THE PROGRAM. We want to understand more about why you left this program. Which of the following best describes your thinking when you left? Feel free to tell us more. You can select more than one option.*
WHILE YOU WERE AWAY FROM THE PROGRAM. We want to understand as much as possible what you went through when you left the program. Which of the following statements best describes your experience? Feel free to tell us more. You can select more than one option. *
Which of the following opioids did you buy?*

SECTION A | EXECUTIVE DIRECTOR OF ADMISSIONS REVIEW

Reviewed by : *
Use your mouse or finger to draw your signature above

SECTION 2 | PREFFERED PHARMACY

IMPORTANT: We do not use CVS or Walmart pharmacies

Medication type preference*
Preferred Pharmacy Address*

SECTION 3 | EMERGENCY CONTACT

Emergency Contact*
Relationship to the patient*

SECTION 4 - INSURANCE AND MEDICAID

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


Our program does not take MEDICAID or 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).

Do you have insurance? Mandatory field*
Do you have Medicaid?- Mandatory field*

SECTION 4A | PRIMARY INSURANCE INFORMATION

Policy Holder Name / Subscriber name*
Policy Holder Date of Birth*
Date Issued*
Patient relationship with policy holder*

SECTION 4B - MEDICAID

Recipient Name*
Recipient Date of Birth*
Issued date*
Primary care provider name (Optional)
Primary care provider address (Optional)

SECTION 5 | MEDICAL HISTORY

Did you take opioids for a prolonged period?*
When you tried to stop taking opioids did you become sick?*
How many of the following symptoms did you have when you stopped taking Opioids? Please check all that apply**

SECTION 6 | 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 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.

I have read and agree to the BUPE.ME Narcotics Agreement. Please select "I agree" below*

SECTION 7 | 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.

I have read and agree to the BUPE.ME Informed Consent. Please select "I agree" below*

SECTION 8 | 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.

I have read and agree to the BUPE.ME Electronic Code of Federal Regulations . Please select "I agree" below*

SECTION 9 | CONTROLLED SUBSTANCE INFORMED CONSENT

I am aware that that I have been diagnosed with autonomic conflict disorder secondary to absence syndrome and will be treated with a partial agnostic opioid that will block opioids by attaching to the opioid receptors without activating them. I further understand that as my body adjust, tapering will be discussed on a one-on-one basis with me.*

SECTION 10 | 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. **

SECTION 11 | 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 *
2 - Effective Period : This authorization for release of information covers the period of healthcare from:**
3 - Extent of Authorization*
3.1 Release Exceptions*
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.*
5 - This authorization shall be in force and effect until:*
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*
7 - I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether sign this authorization.**
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.*
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.*

SECTION 12 | 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.

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