Randy E. Durbin, D.O., P.C. 800 Old Dawson Village Rd., Suite 020 Dawsonville, GA 30534

Transcription

1 Suboxone Patient Information Sheet Today s Date: / / Patient Name: Date of Birth: / / Sex: Male Female Social Security: / / Address: City, State, Zip: Permission to contact via ? Yes No Home Phone ( ) Permission to leave a message? Yes No Cell Phone ( ) Permission to leave a message? Yes No Work Phone ( ) Ext: Permission to leave a message? Yes No Patient Security Word* for phone calls: (e.g. favorite car, pet s name, etc.) Primary Care Doctor/Clinic: Phone: Address: City, State, Zip: Emergency Contact: Last Name: First Name: MI: Relationship: Address: City: State: Zip: Home Phone: ( ) Work Phone: ( ) Ext: Permission to Leave Message: Home: Yes No Work: Yes No Social History: Race: White Black or African American American Indian or Alaska Native Asian Other Declined Ethnicity: Non-Hispanic or Latino Hispanic or Latino Declined Marital Status: Married Single Widowed Divorced Separated Domestic Partnered Number of Children: Their Year(s) of Birth: Religious Affiliation: *Patient Security Word is used to verify identity when there is a verbal release of patient s Protected Health Information over the phone. 1

2 Current Employment Status: Employed Unemployed Disabled Retired Student Occupation and Responsibilities: Place of Employment: Hours Per Week: Hobbies/Recreation (Sports, Music/Arts, Crafts): Please select smoking status: Current (daily) Current (some days) Former Never Smoker, current status unknown Unknown if ever smoked If you are a current smoker, are you interested in a cessation program? Yes No Do you drink alcohol? Yes No If so, how many drinks per week? Have you ever been treated for substance abuse or illegal drug use? Yes No If so, what If so, what type of treatment and where? (e.g. counseling: NA meetings ) _ Are you interested in nutritional counseling and discussing your daily diet? Yes No Do you have concerns about your weight? Yes No If so, are you interested in physician supervised weight loss? Yes No Allergies: Do you have an allergy to tape or adhesives? Yes No Do you have an allergy to latex? Yes No Do you have an allergy to medications? Yes No If so, what drug(s) and what type of reactions (e.g. throat closing or rash )? Do you suffer from seasonal or environmental allergies? Yes No Please list: 2

3 Why are you here today? Please list problem(s): Review of Symptoms: Indicate any of the following symptoms you have had in the past 6 months: Constitutional: None Fatigue Fever Night sweats Weight gain Weight loss Cardiovascular: None Chest Pain/Pressure Heart Palpitations (Skipped Beats) Skin: None Cellulitis Keloid Psoriasis Rash Redness Sores Warmth Gastrointestinal: None Abdominal Pain Constipation Diarrhea Heartburn Nausea Vomiting Genito-urinary: None Kidney Failure Pregnancy (if applicable) Hematology: None Bleeding Blood Clots Bruising Musculoskeletal: None Back Pain Bone Pain Decreased Range of Motion Joint Locking Joint Pain(s) Muscle Pain(s) Muscle Weakness Neck Pain Osteoporosis Shooting Pain Swelling Neurology: None Gait Abnormality Numbness and Tingling Psychiatric: None Alcohol Abuse Anxiety Depression Drug Abuse Stress Respiratory: None Emphysema Shortness of Breath Wheezing Other Medical Problems for which you are or have been treated: Alcoholism Cardiovascular Disease Gastro Reflux Kidney Disease Pulmonary Embolism Alzheimer Cellulitis Heart Disease Liver Disease Rheumatoid Arthritis Anemia Cirrhosis Hepatitis Lupus Seizures Arrhythmia Deep Vein Thrombosis High Cholesterol Mental Illness Stroke Arthritis Depression High Blood Pressure MS Ulcers Asthma Diabetes Hyperthyroidism Osteoporosis Other Bleeding Disorders Fibromyalgia Hypothyroidism Parkinson Other Cancer Gastritis Keloid Psoriasis Other If other please specify: 3

4 List any previous surgeries and note the year they were performed to the right: None Breast Foot Knee Tonsillectomy Abdominal Cardiac Gall Bladder Nasal Vascular Ankle Ear Hand Ovary Wrist Appendectomy Elbow Hip Prostate Bladder Back Eye Hysterectomy Shoulder Facial Indicate any tests or treatments that you have had (include location and year): Injection MRI EMG X-rays CT/CAT Scans Physical Therapy Other Family History: Please check all that apply and indicate family relationship (parent, brother, sister or child) with any of the following conditions: Condition List Relative Condition List Relative Alcoholism Hearing Loss Allergies Heart Disease Alzheimer Disease High Cholesterol Anemia Hypertension Arthritis Asthma Bleeding Disorders Breast Cancer Cancer Cardiovascular Disease Cerebrovascular Disease Crohn Disease Degenerative Joint Disease Depression Diabetes Eczema Epilepsy Gastro Reflux (GERD) Other (please describe using full line) Hyperthyroidism Hypothyroidism Kidney Disease Lupus Mental Illness Multiple Sclerosis Osteoporosis Parkinson Disease Prostate Cancer Rheumatoid Arthritis Seizures Skin Cancer Stroke Ulcerative Colitis 4

5 List any current medications you are taking: Anti-Depressant: Anti-Ulcer: Allergy/Asthma: Effexor (venlafaxine) Prilosec (omeprazole) Allegra (fexofenadine) Cymbalta (duloxetine) Prevacid (lansoprazole) Claritin (loratadine) Prozac (fluoxetine) Nexium (esomeprazole) Singulair (montelukast) Paxil (paroxetine) Protonix (pantoprazole) Zyrtec (cetirizine) Wellbutrin (bupropion) Tagamet (cimetidine) Albuterol Inhaler Zoloft (sertraline) Zantac (ranitidine) Asthma-Steroid Inhaler Nasal Steroids Blood Thinners: Cholesterol Lowering: Diabetes: Aspirin Lipitor (atorvastatin) Insulin Injections Coumadin (warfarin) Zocor (simvastatin) Glucophage (metformin) Refludan (lepirudin) Crestor (rosuvastatin) Glucotrol (glipizide) Ticlid (ticlopidine) Mevacor (lovastatin) Glucagon Plavix (clopidogrel) Niaspan (niacin) Avandia (rosiglitazone) Aggrastat (tirofiban) Gemfibrozil Precose (acarbose) Zetia Cardiac/Hypertension: Pain Medications: Antibiotics: Capoten (captopril) Darvocet Amoxicillin Lisinopril Fentanyl Augmentin Cozaar (losartan) Hydrocodone Bactrim (trimethoprim) Diovan (valsartan) Lyrica Biaxin (clarithromycin) Dyazide MS Contin Cipro Nifedipine Neurontin Cleocin (clindamycin) Verapamil Oxycodone Doxycycline Diltiazem OxyContin Erythromycin Norvasc (amlodipine) Percocet Keflex (cephalexin) Inderal (propranolol) Tylenol #3 Levaquin (levofloxacin) Tenormin (atenolol) Vicodin Lamisil Lopressor (metoprolol) Vistaril Sporanox (itraconazole) Coreg (carvedilol) Zanaflex Zithromax (azithromycin) Toprol Anti Inflammatory Osteoporosis Treatment: Reproductive: Acetaminophen Actonel Birth Control Pills Celebrex Fosamax Depo-Provera Injections Naproxen (Aleve) Boniva Hormone Replacement Ibuprofen Prednisone Other (including vitamins/supplements): 5

6 Psychiatric History Have you ever been diagnosed with depression? Yes No If so, at what age? What medications were you prescribed? Did they work? Yes No Have you ever been diagnosed with Bipolar Depression? Yes No If so, at what age? What medications were you prescribed? Did they work? Yes No Have you ever been diagnosed with Schizophrenia? Yes No If so, at what age? What medications were you prescribed? Did they work? Yes No Have you ever been diagnosed with any other mental health disease? Yes No If so, at what age? What medications were you prescribed? Did they work? Yes No Patient Name (print): Patient Signature: Date: Witness Signature: Date: 6

7 Please answer the following questions which will help us design your plan of treatment for the Buprenorphine-Naloxone Program: What is the best day of the week and time of day for Office Visits? Morning Afternoon Are there any months out of the year when you may have difficulty making your monthly appointment? Are there any special plans (such as a major trip) that you have for the coming year? Work? Home? Other? Are there any problems that make it difficult for you to give routine urine specimens? Do you have any problems that make it hard for you to read labels or count pills? What are your reasons for being interested in Buprenorphine-Naloxone treatment? Are you currently using any illicit drugs or alcohol? Yes No If so, what are you using? Patient Initial: 7

8 If you are not currently using drugs or alcohol, when was the last time you relapsed to use? Are there any known triggers which have put you in danger of relapse in the past, or which might in the future? What coping methods have you developed to deal with these triggers? Are there any significant medical events (such as operations) that you expect you will need in the coming year? What kinds of counseling or therapy help would you like for your drug abuse problem? What are your strengths and skills to handle take-home Buprenorphine-Naloxone? Patient Initial: 8

9 What worries do you have about being responsible for taking this medication on your own, at home? Is anyone in your home actively addicted to, or abusive of, drugs or alcohol? What are the major sources of stress in your life? Are there any things you would particularly like to discuss with the doctor today? Patient Initial: I RELEASE THE ABOVE INFORMATION TO DR. DURBIN FOR USE IN MY TREATMENT AND ATTEST THAT THE INFORMATION CONTAINED IN THIS INTAKE FORM IS TRUE AND CURRENT TO THE EXTENT OF MY KNOWLEDGE. Patient Signature: Date: 9

10 BUPRENORPHINE-NALOXONE MAINTENANCE TREATMENT INFORMATION Suboxone (a tablet with Buprenorphine and Naloxone) is an FDA approved medication for treatment of people with heroin or other opioid addiction. Buprenorphine-Naloxone can be used for detoxification or for maintenance therapy. Maintenance therapy can continue as long as medically necessary. There are other treatments for opiate addiction, including Methadone, Naltrexone, and some treatments without medications that include counseling therapy, groups and meetings. If you are dependent on opiates any opiates - you should be in as much withdrawal as possible when you take the first dose of Buprenorphine-Naloxone. It you are not in withdrawal, Buprenorphine-Naloxone can cause severe induced opiate withdrawal. For that reason, you should take the first dose in the office and remain in the office for at least 2 hours. We recommend that you arrange not to drive after your first dose, because some patients get drowsy until the correct dose is determined for them. Some patients find that it takes several days to get used to the transition from the opiate they had been using to Buprenorphine-Naloxone. During that time, any use of other opiates may cause an increase in symptoms. After you become stabilized on Buprenorphine-Naloxone, it is expected that other opiates will have less effect. Any attempts to override the Buprenorphine- Naloxone by taking more opiates could result in an opiate overdose. You should not take any other medication without discussing it with the physician first. Combining Buprenorphine-Naloxone with alcohol or other sedating medications is dangerous. The combination of Buprenorphine-Naloxone with benzodiazepines (such as Valium, Librium, Ativan, Xanax, Klonopin, etc.) has resulted in deaths. Although sublingual Buprenorphine-Naloxone has not been shown to be liver-damaging, your doctor will monitor your liver tests while you are taking Buprenorphine-Naloxone. The form of Buprenorphine-Naloxone (Suboxone ) you will be taking is a combination of Buprenorphine with a short-acting opiate blocker (Naloxone). It will maintain physical dependence, and if you discontinue it suddenly, you will likely experience withdrawal. If you are not already dependent, you should not take Buprenorphine-Naloxone, as it could eventually cause physical dependence. Buprenorphine-Naloxone tablets (or films) must be held under the tongue until they dissolve completely. You will be given your first dose at the clinic, and you will have to wait in the office as it dissolves, and for two hours after it dissolves, to see how you react. It is important not to talk or swallow until the tablet dissolves. This takes up to ten minutes. Buprenorphine-Naloxone is then absorbed over the next 30 to 120 minutes from the tissue under the tongue. Buprenorphine-Naloxone will not be absorbed from the stomach if it is swallowed. If you swallow the tablet/film, you will not have the important benefits of the medication, and it may not relieve your withdrawal. Most patients end up at a daily dose of 16 mg to 24mg of Buprenorphine-Naloxone (this is roughly equivalent to 60mg of methadone maintenance). Beyond that dose, the effects of Buprenorphine-Naloxone plateau, so there may not be any more benefit to increase in dose. It may take several weeks to determine just the right dose for you. The first dose is usually 2mg. 10

11 If you are transferring to Suboxone from Methadone maintenance, your dose has to be tapered until you have been below 30mg for at least a week. There must be at least 60 hours (preferably longer) between the time you take your last Methadone dose and the time you are given your first dose of Buprenorphine-Naloxone. Your doctor will examine you for clear signs of withdrawal, and you will not be given Buprenorphine-Naloxone until you are in withdrawal. I have read and understand these details about Buprenorphine-Naloxone treatment. I wish to be treated with Buprenorphine-Naloxone. Patient Signature: Date: Witness Signature: Date: 11

12 BUPRENORPHINE-NALOXONE TREATMENT AGREEMENT Patient Name: I am requesting that my doctor provide Buprenorphine-Naloxone treatment for (please specify opioid type) addiction. I freely and voluntarily agree to accept this treatment agreement, as follows: 1. I agree to keep, and be on time to, all my scheduled appointments with the doctor and his/her assistant. 2. I agree to conduct myself in a courteous manner in the physician s or clinic s office. 3. I agree to pay all office fees for this treatment at the time of my visits. I will be given a receipt that I can use to get reimbursement from my insurance company if this treatment is a covered service. I understand that this medication will cost between $5-$10 a day, just for medication, and that the office visits are a separate charge. 4. I agree not to arrive at the office intoxicated or under the influence of drugs. If I do, the staff will not see me and I will not be given any medication until my next scheduled appointment. 5. I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without recourse for appeal. 6. I understand that the use of Buprenorphine-Naloxone/naloxone (Suboxone) by someone who is currently taking other opioids could cause them to experience severe withdrawal. 7. I agree not to deal, steal, or conduct any other illegal or disruptive activities in or in the vicinity of the doctor s office. 8. I agree that my medication (or prescriptions) can only be given to me at my regular office visits. Any missed office visits will result in my not being able to get medication until the next scheduled visit. 9. I agree that the medication I receive is my responsibility and that I will keep it in a safe, secure place. I agree that lost medication will not be replaced regardless of the reasons for such loss. I understand that a fire safe bolted to a wall or floor is an example of an appropriate storage place for my medication. 10. I agree not to obtain medications from any physicians, pharmacists, or other sources without informing my treating physician. I understand that mixing Buprenorphine- Naloxone with other medications, especially benzodiazepines, such as Valium (diazepam), Xanax (alprazolam), Librium (chlordiazepoxide), Ativan (lorazepam), and/or other drugs of abuse including alcohol, can be dangerous. I also understand that a growing number of deaths have been reported in persons mixing Buprenorphine- Naloxone with benzodiazepines. 12

13 11. I agree to take my medication as the doctor and his/her assistant has instructed, and not to alter the way I take my medication without first consulting the doctor. 12. I understand that medication alone is not sufficient treatment for my disease, and I agree to participate in the recommended patient education and relapse prevention/counseling program to assist me in my treatment. 13. I understand that my Buprenorphine-Naloxone treatment may be discontinued and I may be discharged from the clinic if I violate this agreement. 14. I understand that there are alternatives to Buprenorphine-Naloxone treatment for opioid addiction including: a. Medical withdrawal and drug-free treatment b. Naltrexone treatment c. Methadone treatment My doctor will discuss these with me and provide a referral if I request one of these options. I understand that these are not options that Dr. Durbin provides. Patient Signature: Date: / / Witness Signature: Date: / / 13

14 Drug Screen/Criminal Consent Form with Authorization and Acknowledgement I hereby authorize, or his agents to obtain my urine sample for the purpose of conducting drug screening test. I fully understand that my urine drug test will be used to determine if I have taken any illicit substances. I fully understand that my urine drug test is a mandatory procedure as required by the Drug Enforcing Agency (DEA), and I must fully comply with this policy in order to receive pain care and treatment. I fully understand that a positive finding of any illicit substance in my urine drug test is a violation of Policy, and this will be ground for disqualification and termination of my treatment. I hereby certify that my urine specimen is my own and has not been substituted or adulterated. I furthermore agree and grant permission to test my urine specimen for drug metabolites and alcohol. I hereby authorize, to receive any criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency in the United States. Patient Name (Printed) Patient Signature: Date: Witness Signature: Date: 14

15 Notice of Privacy Practices for Protected Health Information This notice describes how health information about you may be shared and how you can get access to this information. Please review it carefully. You have the right to review this notice before signing the consent authorizing use of disclosures of your protected health information. EFFECTIVE DATE: 7/17/2014 If you consent, the medical provider is permitted by Federal Law to make use of and disclose of your health information for the purpose of treatment, payment and health care operations. Protected health information is the information we create and obtain in providing our service to you. Such information may include documenting your symptoms, examination, test results, diagnosis, treatment and applying for future treatment. It also includes billing documents for those services, if applicable. An example of using your health information by a nurse is: An employee of the provider s office obtains treatment information about you and records it in a health record. During the course of your treatment, the provider determines that he/she will need to consult with another specialist in the area. He/ She will share the information with that specialist. An example of using your health information for payment purposes: We provide you with a receipt for payment, which you then submit for reimbursement to your insurance company, if applicable. The insurance company requests information from us regarding the services that were rendered. We will provide that information to them about you and the care that you received. An example of using this information for health care operations: The state licensing authority wants to review records to assure that we have acted constant with state laws regarding your care. At the licensing authority request, we will provide a copy of your chart. Your health information rights: The health and billing records we collect during your visits are considered physical property of this office. The information in it however, belongs to you. You have the right to request a restriction on certain uses and disclosures of your protected health information by delivering the request in writing to our office. We are not required to grant the request but we will comply with any request granted. You may obtain a paper copy of the Notice of Privacy Practices for Protected Health Information by making a request at our office that you are allowed to inspect and receive a copy of your health and billing records. You may exercise this right by delivering the request in writing to our office using the form we provide to you. You may appeal or deny access to your protected health information except in certain circumstances. You may request that your health care records be amended or corrected for incomplete or incorrect information. You may file a statement of disagreement if your amendment is denied and request that the request for amendment and any denial be attached in all future disclosure s of your protected health information. You may obtain an accounting of disclosures of your health information as required to be maintained by law by delivering written request to our office using the form we provide to you. The accounting will not include internal uses of information for treatment, payment or operations. Request that the communication of your health information be made by alternative means should be made by delivering the request in writing to our office using the form we provide. You may revoke any authorizations that you made previously to use or disclose information, except to the extent information or actions have already been taken by delivering a written revocation to our office. 15

16 Acknowledgement of Receipt of Notice of Privacy Practices I acknowledge that I was provided with a copy of the Notice of Privacy Practices and that I have read them or declined the opportunity to read them and understand the notice of privacy practices. I understand that this form will be placed in my patient chart and maintained for at least six years. Patient Name (Printed) Patient Signature: Date: THIS FORM WILL BE PLACED IN THE PATIENT S CHART AND MAINTAINED FOR AT LEAST SIX YEARS. 16

17 Counseling Policy Notice I understand all patients are required to undergo routine counseling and submit a completed counseling log each month while in the Opioid Dependence Therapy (Suboxone) program. I also understand if I fail to do so, I will not be seen for my monthly appointment until the document can be provided to the office. A copy of this signed notice will remain with my chart. Patient Name (Printed) Patient Signature: Date: Witness Signature: Date: 17

18 Payment and Refund Policy 1. Payment is required in full at the time of service we cannot process credit/debit cards at a date after service. 2. We require 12 hour notice to reschedule appointments. No-shows will result in a $25 appointment cancellation fee. 3. We are unable to accept checks. NO REFUNDS WILL BE GRANTED FOR: 1. Failing a urine analysis (having positive illegal drugs in your system) 2. Any unlawful activity 3. Counterfeit or modified medical records or other documentation. 4. Failure to provide required medical records including, but not limited to the following: a. MRI b. Medical History c. Referral/Documents from previous physician d. Previous pharmacy records 5. An appointment wherein you are given a discharge notice. Any refund requested for any reason other than those listed will be on considered on an individual basis. If you have any questions you may speak to the office manager. I UNDERSTAND THAT IT IS MY SOLE RESPONSIBILITY TO SEEK THIRD PARTY REIMBURESEMENT (e.g. submitting to Blue Cross Blue Shield or Humana), IF APPLICABLE. Patient Name (Printed) Patient Signature: Date: Witness Signature: Date: 18

19 Authorization for Release of Protected Health Information Patients full name at the time of treatment: Date of Birth: / / Social Security number: - - I authorize (or other physician or health facility) to release my Medical Records to:, Information to be released: Initial medical examination Progress notes from to X-Ray/CRCT/MRI Scan Reports Pharmacy Records Lab Results Discharge Summary Other 1) I understand that if my records contain documentation of alcohol abuse, psychiatric condition, drug abuse, or communicable diseases, that this information will be released as part of my record. 2) I understand that if the person or entity receiving this information is not covered by federal privacy regulations, this information will no longer be protected and may be re-disclosed. 3) I understand that I may revoke this authorization at any time, but revocation will not apply to information that has already been released. 4) I understand that a copy or FAX of this document is just as valid as the original document. 5) I understand that my records are protected under the Federal regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. 6) I understand that this notice will stay in my chart and be considered valid until I revoke this consent in writing, or until my patient-physician relationship with Dr. Durbin is dissolved. Patient Name (Printed) Patient Signature: Date: Witness Signature: Date: 19