WELCOME TO OUR PRACTICE

Transcription

1 979 E. Third ST, STE A-240 Chattanooga, TN Phone- (423) Fax- (423) WELCOME TO OUR PRACTICE I wanted to thank you for choosing ReNu Chattanooga. I pledge to you that my staff and I will do our best to provide you and your family with high quality, state-of-the-art care in a professional and comfortable environment. Enclosed with this letter are some forms I need you to complete and have with you when you come to your appointment. Having these completed and ready when you arrive will speed yours and other patient s wait time. We look forward to your visit. If you have any questions before then, please call the office at (423) Sincerely, Paula Nicola, MD

2 979 E. Third ST, STE A-240 Chattanooga, TN Phone- (423) Fax- (423) WELCOME TO OUR PRACTICE I wanted to thank you for choosing ReNu Chattanooga. I pledge to you that my staff and I will do our best to provide you and your family with high quality, state-of-the-art care in a professional and comfortable environment. Enclosed with this letter are some forms I need you to complete and have with you when you come to your appointment. Having these completed and ready when you arrive will speed yours and other patient s wait time. We look forward to your visit. If you have any questions before then, please call the office at (423) Sincerely, Paula Nicola, MD

3 PAULA NICOLA, M.D. ERLANGER MEDICAL MALL 979 EAST THIRD STREET. SUITE 240 CHATTANOOGA, TN PHONE FAX Registration Form PATIENT INFORMATION Patient Full Name: Marital Status: SSN: Street Address: Birthdate: Age: Sex: City: State: Zip: Home or Cell Phone: CONTACT PREFERENCES: Emergency Contact Name: Relationship: Phone: Restrictions The above person is authorized to receive information from ReNu Chattanooga regarding my care. This information may include but is not limited to test results, appointment information, and account information etc. Initial PRIVACY POLICY I acknowledge that I have read and fully understand the Notice of Privacy Practices given to me with this form. Initial FINANCIAL POLICY AGREEMENT ReNu Chattanooga does not accept or file to any insurance plans. These services will be provided on a self pay basis and all fees will need to be paid upfront prior to being seen. $375-First visit with induction (covers first 28 days of treatment only) (Medication is not included) $175- Each visit after the first 28 days of treatment We accept cash, checks, visa, mastercard and discover I understand and agree to pay all fees upfront prior to being seen. Intial The above information is true to the best of my knowledge. Patient Signature: Date:

4 PAULA NICOLA, M.D. ERLANGER MEDICAL MALL 979 EAST THIRD STREET. SUITE 240 CHATTANOOGA, TN PHONE FAX Patient Treatment Contract Patient Name: Date: As a participant in medication treatment for opioid misuse and dependence, I freely and voluntarily agree to accept this treatment contract as follows: 1. I agree to keep and be on time to all of my scheduled appointments. A $50.00 fee will be assessed to any patient who does not keep a scheduled appointment and does not call 2 hours prior to the appointment time to reschedule. This $50.00 fee must be paid prior to being seen again by the doctor or receiving any future prescriptions. Initial 2. I agree to adhere to the payment policy outlined by this office. ReNu Chattanooga and Dr. Nicola do not file any insurance for your office visits. All office visits must be paid in full prior to being seen by the doctor. Payment can be by Cash or Debit/Credit Card only. Initial 3. I agree to conduct myself in a courteous manner while at the doctor s office to other patients, to the office staff and to Dr. Nicola. Initial 4. I agree to be properly dressed for all appointments. Any patient who shows up for an appointment looking unkempt will be discharged from the practice. Initial 5. I agree to report my history and symptoms honestly to my doctor and the office staff. I will inform my doctor about any medications (prescription and non-prescription) that I am taking. I will report any changes in my medical history, such as becoming pregnant. Initial 6. I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is illegal and is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal. Initial 7. I understand that my medication must be stored safely, where it cannot be taken accidentally by children or pets, or stolen. If anyone else, including a child, takes my medication, I will call 911 or Poison Control immediately. Initial 8. I agree not to deal drugs, steal, or conduct any illegal or disruptive activities in or around the doctor s office. Initial 9. I understand that if dealing or stealing or if any illegal or disruptive activities are observed or suspected by employees of the pharmacy where my medication is filled, that the behavior will be reported to my doctor s office and could result in my treatment being terminated without any recourse for appeal. Initial 10. I agree that my prescription can only be given to me at my regular office visits. A missed visit will result in my not being able to get my prescription until the next scheduled visit. Initial 11. I will be careful with my take-home prescription supplies of my medication as I understand that Suboxone film and all other buprenorphine-containing medications are potent and very dangerous for children. Even small amounts or a brief exposure to Suboxone film/buprenorphine products can lead to permanent damage and/or death in children. Initial 12. I understand that at every visit, my doctor may ask me to bring my unused supply of medication for a medication count and that I may not get a refill if I do not bring my medication with me. This includes empty film pouches which will be counted by the staff at each visit. Initial

5 13. I agree that the medication I receive is my responsibility and I agree to keep it in a safe, secure place. I agree that lost medication will not be replaced regardless of why it was lost. Initial 14. I agree not to obtain medications from any doctors, pharmacies, or other sources without telling my treating physician. Initial 15. I understand that mixing this medicine with other medications, especially benzodiazepines (for example, Valium, Ativan, Klonopin, or Xanax) can be dangerous. I also recognize that several deaths have occurred among persons mixing buprenorphine and benzodiazepines (especially if taken outside the care of a physician, using routes of administration other than sublingual or in higher than recommended therapeutic doses). Initial 16. I agree to read the Medication Guide and consult my doctor should I have any questions or experience any adverse events. Initial 17. I agree to take my medication as my doctor has instructed and not to alter the way I take my medication without first consulting my doctor. Initial 18. I understand that medication alone is not sufficient treatment for my condition, and I agree to participate in counseling as discussed and agreed upon with my doctor and specified in my treatment plan. Prescriptions may be withheld if I do not participate in some form of counseling at the discretion of the doctor. Initial 19. I agree to abstain from alcohol, opioids, marijuana, cocaine and other addictive substances (except nicotine). Initial 20. I agree to provide random urine samples as requested. Initial 21. I understand that violations of the above may be grounds for termination of treatment. Initial 22. I understand that ReNu Chattanooga shares office space with another practice. I agree to only come by the office on the date and time of my scheduled appointment to see Dr. Nicola. She will not be available at times outside of this to provide prescriptions for Suboxone film or any other medications. Initial 23. I understand that Dr. Nicola will only prescribe Suboxone film therapy except under very particular circumstances (i.e. pregnancy). No monotherapy product such as Subutex will be prescribed. Initial Patient Signature: Date:

6 NOTICE OF PRIVACY PRACTICES ReNu Chattanooga 979 E Third ST STE A240 Chattanooga, TN (423) Treatment-We use medical information about you to provide your medical care. We disclose medical information to our employees and others who are involved in providing the care you need. For example, we may share your medical information with other physicians or other health care providers who will provide services that we do not provide. Or we may share this information with a pharmacist who needs it to dispense a prescription to you, or a laboratory that performs a test. We may also disclose medical information to members of your family or others who can help you when you are sick or injured, or after you die. Payment- We use and disclose medical information about you to obtain payment for the services we provide. For example, we give your health plan the information it requires before it will pay us. We may also disclose information to other health care providers to assist them in obtaining payment for services they have provided to you. Health Care Operations-We may use and disclose medical information about you to operate this medical practice. For example, we may use and disclose this information to review and improve the quality of care we provide, or the competence and qualifications of our professional staff. Or we may use and disclose this information to get your health plan to authorize services or referrals. We may also use and disclose this information as necessary for medical reviews, legal services and audits, including fraud and abuse detection and compliance programs and business planning and management. We may also share your medical information with our "business associates," such as our billing service, that perform administrative services for us. We have a written contract with each of these business associates that contains terms requiring them and their subcontractors to protect the confidentiality and security of your protected health information. We may also share your information with other health care providers, health care clearinghouses or health plans that have a relationship with you, when they request this information to help them with their quality assessment and improvement activities, their patient-safety activities, their population-based efforts to improve health or reduce health care costs, their protocol development, case management or care-coordination activities, their review of competence, qualifications and performance of health care professionals, their training programs, their accreditation, certification or licensing activities, or their health care fraud and abuse detection and compliance efforts. Sale of Health Information- We will not sell your health information without your prior written authorization. The authorization will disclose that we will receive compensation for your health information if you authorize us to sell it, and we will stop any future sales of your information to the extent that you revoke that authorization. Required by Law- As required by law, we will use and disclose your health information, but we will limit our use or disclosure to the relevant requirements of the law. When the law requires us to report abuse, neglect or domestic violence, or respond to judicial or administrative proceedings, or to law enforcement officials, we will further comply with the requirement set forth below concerning those activities. Public Health- We may, and are sometimes required by law, to disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child, elder or dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or

7 Infection exposure- When we report suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative promptly unless in our best professional judgment, we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm. Health Oversight Activities- We may, and are sometimes required by law, to disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure and other proceedings, subject to the limitations imposed by law. Judicial and Administrative Proceedings-We may, and are sometimes required by law, to disclose your health information in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a court or administrative order. Law Enforcement-We may, and are sometimes required by law, to disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order, warrant, grand jury subpoena and other law enforcement purposes. Coroners-We may, and are often required by law, to disclose your health information to coroners in connection with their investigations of deaths. Public Safety-We may, and are sometimes required by law, to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public. Specialized Government Functions-We may disclose your health information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody. Change of Ownership-In the event that this medical practice is sold or merged with another organization, your health information/record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another physician or medical group. Breach Notification. In the case of a breach of unsecured protected health information, we will notify you as required by law. If you have provided us with a current address, we may use to communicate information related to the breach. In some circumstances our business associate may provide the notification. We may also provide notification by other methods as appropriate. Psychotherapy Notes-We will not use or disclose your psychotherapy notes without your prior written authorization except for the following: 1) use by the originator of the notes for your treatment, 2) for training our staff, students and other trainees, 3) to defend ourselves if you sue us or bring some other legal proceeding, 4) if the law requires us to disclose the information to you or the Secretary of HHS or for some other reason, 5) in response to health oversight activities concerning your psychotherapist, 6) to avert a serious and imminent threat to health or safety, or 7) to the coroner or medical examiner after you die. To the extent you revoke an authorization to use or disclose your psychotherapy notes, we will stop using or disclosing these notes.

8 Research- We may disclose your health information to researchers conducting research with respect to which your written authorization is not required as approved by an Institutional Review Board or privacy board, in compliance with governing law. You re Health Information Rights: Right to Request Special Privacy Protections-You have the right to request restrictions on certain uses and disclosures of your health information by a written request specifying what information you want to limit, and what limitations on our use or disclosure of that information you wish to have imposed. If you tell us not to disclose information to your commercial health plan concerning health care items or services for which you paid for in full out-of-pocket, we will abide by your request, unless we must disclose the information for treatment or legal reasons. We reserve the right to accept or reject any other request, and will notify you of our decision. Right to Request Confidential Communications- You have the right to request that you receive your health information in a specific way or at a specific location. For example, you may ask that we send information to a particular account or to your work address. We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications. Right to Inspect and Copy- You have the right to inspect and copy your health information, with limited exceptions. To access your medical information, you must submit a written request detailing what information you want access to, whether you want to inspect it or get a copy of it, and if you want a copy, your preferred form and format. We will provide copies in your requested form and format if it is readily producible, or we will provide you with an alternative format you find acceptable, or if we can't agree and we maintain the record in an electronic format, your choice of a readable electronic or hardcopy format. We will also send a copy to any other person you designate in writing. We will charge a reasonable fee which covers our costs for labor, supplies, postage, and if requested and agreed to in advance, the cost of preparing an explanation or summary. We may deny your request under limited circumstances. If we deny your request to access your child's records or the records of an incapacitated adult you are representing because we believe allowing access would be reasonably likely to cause substantial harm to the patient, you will have a right to appeal our decision. If we deny your request to access your psychotherapy notes, you will have the right to have them transferred to another mental health professional. Right to Amend or Supplement- You have a right to request that we amend your health information that you believe is incorrect or incomplete. You must make a request to amend in writing, and include the reasons you believe the information is inaccurate or incomplete. We are not required to change your health information, and will provide you with information about this medical practice's denial and how you can disagree with the denial. We may deny your request if we do not have the information, if we did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and complete as is. If we deny your request, you may submit a written statement of your disagreement with that decision, and we may, in tum, prepare a written rebuttal. All information related to any request to amend will be maintained and disclosed in conjunction with any subsequent disclosure of the disputed information.

9 Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information made by this medical practice, except that this medical practice does not have to account for the disclosures provided to you or pursuant to your written authorization, or as described in paragraphs 1 (treatment), 2 (payment), 3 (health care operations), 6 (notification and communication with family) and 18 (specialized government functions) of Section A of this Notice of Privacy Practices or disclosures for purposes of research or public health which exclude direct patient identifiers, or which are incident to a use or disclosure otherwise prohibited or authorized by law, or the disclosures to a health oversight agency or law enforcement official to the extent this medical practice has received notice from that agency or official that providing this accounting would be reasonably likely to impede their activities. Right to a Paper or Electronic Copy of this Notice- You have a right to notice of our legal duties and privacy practices with respect to your health information, including a right to a paper copy of this Notice of Privacy Practices, even if you have previously requested its receipt by-mail. Except as described in this Notice of Privacy Practices, this medical practice will, consistent with its legal obligations, not use or disclose health information which identifies you without your written authorization. If you do authorize this medical practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. Complaints about this Notice of Privacy Practices or how this medical practice handles your health information should be directed to our Privacy Officer: Steve Nicola, privacy officer for ReNu Chattanooga (423) If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to: TN Secretary of Health & Human Services at address 311 M L King Blvd, Chattanooga, TN You may find a complaint form at: You will not be penalized in any way for filing a complaint.

10 PAULA NICOLA, M.D. ERLANGER MEDICAL MALL 979 EAST THIRD STREET. SUITE 240 CHATTANOOGA, TN PHONE FAX Explanation of First Visit/Induction Your first visit is generally the longest, and may last anywhere from 1 to 4 hours. When preparing for your first office visit, there are a couple of logistical issues you may want to consider: You may not be able to return to work/begin work shift following your visit this is very normal so just plan accordingly Because the medication can cause drowsiness and slow reaction times, particularly during the first few weeks of treatment, you may want to make arrangements for a ride home It is very important to arrive for your first visit already experiencing moderate opioid withdrawal symptoms. If you are in withdrawal, the medicine is supposed to help lessen the symptoms. However, if you are not in withdrawal, the medicine will override the opioids already in your system, which will cause severe withdrawal symptoms. The following guidelines are provided to ensure you are in withdrawal for the visit. If this concerns you, it may help to schedule your first visit in the morning; some patients find it easiest to skip what would normally be their first dose of the day. No methadone or long-acting painkillers for at least 24 hours. No heroin or short-acting painkillers for at least 4 to 6 hours Bring ALL medication bottles with you to your first appointment. Before you can be seen by the doctor, all of the paperwork your doctor provided must be completed. If your doctor provided the paperwork to you prior to this visit, bring it completed or arrive about 30 minutes early to fill it out. Urine drug screening is a regular procedure of treatment, because it provides physicians with important insights into your health and your treatment. Your first visit will include urine drug screening and may also entail blood work. If you haven t had a recent physical exam, your doctor may require one. To help ensure that this medicine is the best treatment option for you, your doctor will perform a substance dependence assessment and mental status evaluation. Lastly, you and your doctor will discuss the medicine and your expectations of treatment. After this portion of your visit is completed, your doctor will administer your first dose. Your doctor will have you the fill the prescription they provide you at this appointment at the pharmacy and return to the doctor s office so you can take the medication under observation. Once you take your first dose, you should begin to feel better within 30 minutes. Your doctor may choose to give you additional doses while you are in the office. It s important that you are honest about how you are feeling during induction so your doctor can find the appropriate dose for you. When you leave the office, the doctor will likely give you a prescription that will last until your next appointment. The doctor may also want to discuss counseling with you, since medication plus counseling has been shown to produce better results. At the same time, your doctor may suggest enrolling in the Here to Help Program, which can provide you with an added support system.

11 Your doctor may ask you to keep a record of any medications you take at home to control withdrawal symptoms. You will also receive instructions on how to contact your doctor in emergency, as well as additional information about treatment. Your Checklist for Your First Visit at ReNu Chattanooga: Arrive experiencing moderate opioid withdrawal symptoms Arrive prepared to give a urine sample for screening Bring completed forms (or come 30 minutes early) Bring ALL medication bottles Bring all fees due at time of visit (cash or credit card only) Please see your doctor or pharmacist for full product information for your medicine.

12 PAULA NICOLA, M.D. ERLANGER MEDICAL MALL 979 EAST THIRD STREET. SUITE 240 CHATTANOOGA, TN PHONE FAX Consent to Treatment with Buprenorphine Suboxone (a tablet with buprenorphine and naloxone) is an FDA-approved medication for treatment of people with opioid or heroin addiction. Buprenorphine 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, and some treatments without medications that include counseling, 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. If you are not in withdrawal, buprenorphine can cause severe opiate withdrawal. For that reason, you should take the first dose in the office and remain in the office for at least an hour. 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. During that time, any use of other opiates may cause an increase in symptoms. After you become stabilized on buprenorphine, it is expected that other opiates will have less effect. Attempts to override the buprenorphine by taking more opiates could result in an opioid overdose. You should not take any other medication without discussing it with Dr. Nicola first. Combining buprenorphine with alcohol or other sedating medications is dangerous. The combination of buprenorphine with benzodiazepines (such as Valium, Librium, Ativan, Xanax, Klonopin, etc.) has resulted in deaths. The form of buprenorphine (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, since it could eventually cause physical dependence. Buprenorphine strips must be held under the tongue until they dissolve completely. It is important not to talk or swallow until the strip dissolves. This takes up to ten minutes. Buprenorphine is then absorbed over the next 30 to 120 minutes from the tissue under the tongue. Buprenorphine will not be absorbed from the stomach if it is swallowed. If you swallow the strip, 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 12 mg to 24 mg of buprenorphine (this is roughly equivalent to 60 mg of methadone maintenance). Beyond that dose, the effects of buprenorphine plateau, so there may not be any more benefit to an increase in dose. It may take several weeks to determine just the right dose for you. The first dose is usually 8 mg and will be given in the office. If you are transferring to Suboxone from methadone maintenance, your dose has to be tapered until you have been below 30 mg for at least a week. There must be at least 24 hours (preferably longer) between the time you take your last methadone dose and the time you are given your first dose of buprenorphine. On the day of induction onto buprenorphine, you should come to the office already in opiate withdrawal. The day before induction, you must not have used any opiate (heroin, methadone, codeine, or other opiate-containing medications). If there are not observable signs of opiate withdrawal, my induction onto buprenorphine may be delayed a day or more. I understand that take home doses and frequency of visits will be determined by how well I am doing, but will be at least monthly.

13 I understand that the goal of treatment of opiate dependency is to learn to live without abuse of drugs. Buprenorphine treatment will be continued as long as necessary to prevent relapse to opiate abuse/dependence. I understand that I cannot drive motor vehicles or use power tools or other dangerous machinery during my first days of taking buprenorphine, to make sure that I can tolerate taking it without becoming sleepy or clumsy as a side effect of taking it. I understand the need to be open and honest with Dr. Nicola and the staff at ReNu Chattanooga regarding my cravings, my potential to relapse to the extent that I am aware of such, and specifically about any relapses which have occurred before a drug test result shows it. For women only: The safety of taking Suboxone during pregnancy is unknown. I am not pregnant, and I will not attempt to become pregnant while taking Suboxone. I agree to not have unprotected sex while I am taking buprenorphine. I agree to tell my physician if I become pregnant or even think I may be pregnant. I understand that Dr. Nicola will likely discontinue Suboxone treatment if I become pregnant or may consider a switch to Subutex therapy upon consultation with a high risk obstetrician. I have read and understand these details about buprenorphine treatment. I wish to be treated with buprenorphine. Patient Signature: Date: Physician Signature: Date:

14 ReNu Chattanooga Paula C. Nicola, MD 979 East Third Street, STE A240 Chattanooga, TN Phone (423) Fax (423) AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION Patient s Name: Date of Birth: Social Security # I request and authorize to release healthcare information of the patient named above to: Name: Address: This request and authorization applies to : Healthcare information relating to the following treatment, condition, or dates: All healthcare information Other: I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above. Yes No Patient Signature: Date Signed: **This authorization will expire one year form date signed unless a written request is received to revoke this authorization prior to the expiration date**