Informed Consent for Suboxone Treatment (Buprenorphine-Naloxone)

OVERVIEW

Buprenorphine (Suboxone) is a medication used to treat Opioid Use Disorder

(OUD). OUD is a medical condition that occurs when opioid use causes negative

effects on health, relationships, responsibilities, and quality of life. This is not a

problem of willpower—it is a medical condition that requires treatment.

Buprenorphine helps by: Reducing withdrawal symptoms, Decreasing cravings,

Providing safer, more stable management compared to other opioids.

BENEFITS OF TREATMENT

· Safer than other opioids (less risk of overdose)

· Helps reduce or stop opioid misuse

· Provides similar pain relief to other opioids

· Improves mental clarity and daily functioning

RISKS AND SIDE EFFECTS

Like all medications, buprenorphine may have side effects, including:

Drowsiness or sleepiness, Constipation, Nausea, upset stomach, or vomiting,

Sweating, headaches, or body aches.

Do not mix buprenorphine with alcohol, benzodiazepines (e.g., Xanax, Ativan,

Klonopin), or sleeping pills, as this can be dangerous.

If you need surgery or treatment for pain, tell your doctors you are taking

buprenorphine.

TREATMENT

You must be in moderate withdrawal before your first dose; otherwise,

buprenorphine can make withdrawal worse.Your provider will guide you on the

correct timing of your first dose and make adjustments as needed.

Some people may take buprenorphine for months; others for years.

Research shows long-term use lowers the risk of relapse.

If you want to stop, do not quit suddenly. Talk with your provider about a safe

taper plan.

To comply with FDA and DEA regulations, patients must agree to the following:

Prescriptions will only be written according to federal guidelines.

Early refills are not allowed.

Refills require an appointment at the interval set by your provider.

You must use one designated pharmacy for all prescriptions.

Lost or stolen prescriptions will not be replaced unless you file a police report

and provide a copy to your provider.

PATIENT RESPONSIBILITIES

1. Take medication only as prescribed

2. Never share or sell medication

3. Keep medication in a safe, secure place

4. Attend all scheduled appointments

5. Provide urine drug screens as requested

6. Report any side effects or concerns to your provider promptly

FEE FOR SERVICE

It is your responsibility to inquire about fee for service with the Behavioral

Health Solutions Administration (BHS), if needed. Regardless of negotiated fee

arrangements and/or insurance coverage, payment for services is your

responsibility and due at the time of your appointment or billing statement date.

If filing with insurance, you are ultimately responsible for any claims not paid

by your insurance company for any reason. Behavioral Health Solutions requires

clients to submit a credit card authorization. Payment is expected at the time of

your appointment. Your session fee, co-pay, co-insurance, deductibles, late

cancellations fees, and missed appointments fees will be charged to the credit

card on file. If your account has not been paid for more than 30 days, or you

accrue a balance greater than $150, services will be paused until your balance is

paid in full or a payment plan is setup. It is counterproductive to the therapeutic

process to add financial stressors to it. In cases where arrangements for payment

have not been agreed upon, BHS has the option of using legal means to secure

the payment. This may involve hiring a collection agency. The personal

information and insurance information provided is complete and accurate. I

authorize the release of any information necessary to file an insurance claim on

my behalf and I assign insurance benefits to be paid to Behavioral Health

Solutions.

I understand that payment for copays and deductibles

are required at the time services are rendered. In the event that my insurance

company denies a claim, I will become financially responsible for all amounts

not covered, payable to Behavioral Health Solutions. I agree to be contacted by

telephone, mail or email according to the contact information that I have

provided. I understand if outstanding balances are due for more than 90 days

without payment, Behavioral Health Solutions may turn over the outstanding

balance due to a collections agency and that I will be financially responsible for

additional collections costs.

Insurance Disclaimer: A quote of benefits and/or authorization does not

guarantee payment or verify eligibility. Payment of benefits are subject to all

terms, conditions, limitations, and exclusions of the member’s contract at time

of service. Behavioral Health Solutions will attempt to verify your health

insurance benefits and/or necessary authorizations on your behalf. PLEASE

NOTE: this is only a quote of benefits and/or authorization. We cannot guarantee

payment or verification eligibility as conveyed by your health insurance provider

will be accurate and complete. Payment of benefits are subject to all terms,

conditions, limitations, and exclusions of the member’s contract at the time of

service.

Insurance Liability for Payment: Your health insurance company will only

pay for services that it determines to be “reasonable and necessary.” Every effort

will be made by this office to have all services and procedures pre authorized by

your health insurance company, when applicable. If your health insurance

company determines that a particular service is not reasonable and necessary, or

that a particular service is not covered under the plan, your insurer will deny

payment for that service. We suggest to all patients that they contact their

insurance to confirm that these services are covered. Under this arrangement,

you are responsible for paying your co-pay, any noncovered portions, and any

deductible you have yet to cover. In addition, if your insurance company does

not pay for our services, you agree to pay for the services provided.

Insurance Referral/Pre-Certification/Authorization of Services: Many insurance

companies may require preauthorization of services. Please know that it is your

responsibility to obtain authorization of services for an out-of-network provider

if needed. You will be responsible for any charges not covered by insurance due

to lack of precertification/authorization for an out-of-network provider. Please

contact BHS administration if you need assistance with this process. Refunds are

only issued when an overpayment has been identified. If you feel there has been

an overpayment, please contact Behavioral Health Solutions’ office. We do NOT

accept personal checks.

Beneficiary Agreement: I understand that my health insurance company may

deny payment for the services identified above, for the reasons stated. If my

health insurance company denies payment, I agree to be personally and fully

responsible for payment. I also understand that if my health insurance company

does make payment for services, I will be responsible for any co-payment,

deductible, or coinsurance that applies: You are entitled to receive this “Good

Faith Estimate” of what the charges could be for Mental Health services provided

to you. While it is not possible for a provider to know, in advance, how many

visits may be necessary or appropriate for a given person, this form provides an

estimate of the cost of services provided. Your total cost of services will depend

upon the number of visits you attend, your individual circumstances, and the type

and amount of services that are provided to you. This estimate is not a contract

and does not obligate you to obtain any services from the provider(s) listed, nor

does it include any services rendered to you that are not identified here. This

Good Faith Estimate is not intended to serve as a recommendation for treatment

nor a prediction that you may need to attend a specified number of Mental Health

visits. The number of visits that are appropriate in your case, and the estimated

cost for those services, depends on your needs and what you agree to in

consultation with your provider. You are entitled to disagree with any

recommendations made to you concerning your treatment and you may

discontinue treatment at any time. I agree to Behavioral Health Solutions

charging my session payment, co-pay, co-insurance, deductibles, late

cancellations fees, and missed appointments fees to the credit card on file

ACKNOWLEDGEMENT AND CONSENT

I understand that buprenorphine is used to treat Opioid Use Disorder and that:

The risks, benefits, and alternatives have been explained to me.

I understand how to take the medication and what precautions to follow.

I agree to follow this treatment plan and the prescribing rules outlined above and

instructed by my provider.

I understand that failure to follow this agreement may result in discontinuation

of buprenorphine prescribing