• As a patient in WellCare Medical Clinic, I freely and voluntarily agree to accept this treatment agreement.
• I agree and understand WellCare Medical Clinic treatment consist of medical assistants, case managers, therapists, and medical providers. My treatment related information can be shared among employees.
• I agree to arrive at my scheduled appointments. I will call the office if I am running late or if I need to reschedule my appointment.
• I agree to conduct myself in a courteous and respectful manner. I will not arrive to clinic under influence of illicit drugs.
• I agree, I am solely responsible for making follow-up appointments and updating pharmacy.
• I agree not to sell, share, or give my medication to anyone including family and friends. I understand mishandling or any suspicious activity can result in a change of medication, referral to higher level of treatment or discharge from the program.
• I agree to continue NA, AA, IOP or counseling services.
• I agree not to alter or adulterate my urines. Consequences includes changes in treatment/medication or possible discharge from the program
due to dishonesty.
• I agree not to conduct any illegal, threating, or disrupting activities in the clinic.
• I agree to be respectful to staff and patients in the clinic.
• I agree that this is my responsibility to keep my medication safe in lock box away from public places. I will keep my medication away from children and minors. If my medication is lost or stolen, then it is my responsibility to call 911 to file complaint and call the insurance and the clinic to prevent the gap in treatment and possible relapse.
• I agree that I will keep my medication in a container with pharmacy/prescription label on it.
• I agree that it is my responsibility to update my PCP, emergency department or any medical personal that I am prescribed suboxone. I will call the clinic for any scheduled dental procedures or selective surgeries. I will call the office if I am not sure of certain medication contraindications with suboxone including over the counter medications including vitamins and supplements.
• I agree and have given permission to WellCare Medical Clinic
to access the prescription Drug Monitoring Program (PDMP) to review my medical
history including ER visits, medications, and regular visits.
• I agree not to do doctor or pharmacy shopping. I will try to keep one pharmacy and provider for treatment adherence.
• I agree not to combine buprenorphine with other illicits including Cocaine, BENZO, alcohol, stimulant, PCP due the high potential for abuse, physical, and psychological dependence. Continuous use can lead to abdominal cramping, irregular heartbeat, stroke, seizures, memory loss, nose bleeds, death, among other symptoms but not limited to.
• I agree, to update WellCare Medical clinic regarding my pregnancy, breast feeding or planning of becoming pregnant.
• I agree to take my suboxone/zubsolv, comfort medications or any other medications as prescribed by WellCare Medical Care provider.
• I agree to random urine monitoring and medication counts. I agree that it is my responsibility to give updated phone number and address. If I receive a call for random counts, then it is responsibility to answer the call at my earliest convenience within 24 hours.
• I agree that I will be honest about my struggles.
• I understand WellCare Medical Clinic performs in-office urine tests and the also sent out to lab for conformation.
• I agree to participate in patient education, counseling and relapse prevention programs to assist me in my treatment.
• I understand to call the clinic if holdover meds are needed for few days for family emergency or vacations.
• I agree to all the conditions as listed above.
• I am giving permission to WellCare Medical Clinic to prescribe the suboxone/zubsolv/subutex for my treatment.