As a participant in Buprenorphine treatment for opioid dependence, I freely and voluntarily agree to accept this contract as follows:

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1. I give Forever Well LLC, EverWell Medical, LLC and Journey Medical, LLC permission to communicate with me via phone, text, or email.

2. It is ultimately my responsibility to:

   1. keep and be on time to all scheduled appointments

   2. double check my prescription 

   3. ask all the necessary questions before leaving the office 

3. I agree to conduct myself in a courteous manner in the doctor’s office.

4. I understand that I am paying for a medical service, not a prescription.

5. If you need a receipt for your visit, please ask the staff for an itemized receipt before leaving the office. I agree to pay a $20 fee for generating (3) three or more receipts. 

6. I agree to assume ALL the risks stated in the “Buprenorphine Consent to Treatment Form”

7. I understand that if there are any reports of dealing or stealing my medication or if any illegal or disruptive activities are observed by employees of the pharmacy where my buprenorphine is filled, the behavior will be reported to my doctor’s office and this could result in my treatment being terminated without any recourse for appeal.

8. I will be asked to turn in a hand-written prescription once every 28 days to the pharmacy.

9. I understand that it will take time for the staff to phone in my refill prescription which will be called into the pharmacy voicemail unless that is not an option. 

10. I understand that calling the office excessively will only slow down the particular response I am requesting.

11. I understand that skipping doses or stretching my medicine could result in the lowering of my dosage. Also, by stretching my medicine beyond my scheduled appointment, I will be asked to report to the office for a visit before I can receive another prescription.

12. I agree that the medication I receive is my responsibility and I agree to keep it in a safe, secure place.  I understand that lost medication WILL NOT be replaced regardless of why it was lost or stolen. Also, I agree that if there has been a theft of my medications, I will report this to the police and will bring a copy of the police report to my next visit.

13. I agree to not obtain medications from any doctors, pharmacies, or other sources without telling my treating physician.

14. 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.

15. I agree to abstain from alcohol, opioids, marijuana, cocaine, methamphetamines, and other addictive substances (except nicotine and caffeine).

16. I understand I could be called upon to report to the office for random drug screens, random pill counts, additional counseling, or doctor visits outside of my scheduled appointments. Failure to do so could result in interruption of prescription, or a written warning.

17. I understand that the physician can cancel my refills of medication at the pharmacy if he/she receives any concerning information or determines that I will no longer be taking a particular medicine.

18. Urine drug screen are used for:

    • To monitor your use of Buprenorphine to control opiate abuse, or 

    • Determine a patient’s continued use of other un-prescribed medications or street drugs 

    • Urine drug screens will be collected and checked by the staff for appropriate metabolites. If there is any suspicion of abuse, a warning letter will be issued, and I will be required to adjust my behavior so as to comply with the clinic’s protocols.

19. I agree to provide random urine samples.

20. I agree to cooperate and consent to an observed urine drug screen (UDS) whenever requested by staff, to confirm if I have been using any alcohol, prescription drugs, or street drugs. A witnessed UDS will also be required each visit if I refuse to submit to a DNA swab conducted by the lab.

21. I agree to keep my correct phone number or an alternate number on file to be reachable for random pill counts or rescheduling of appointments by the doctor.

22. I agree if I have insurance and I have not had a consistent urine drug screen within a 30-day period and the insurance requires any Prior Authorization, the doctor’s office may decline or refuse to administrate the proper papers to the insurance company.

23. I agree I will not discuss my treatment plan or my fees with any other patient in the doctor’s office. If this activity is reported to any employee or physician, my actions may result in consequences.

24. I agree to pay ALL late appointment and/or failed urine UDS fees as required by the doctor’s office.  If fees are not paid in full by the required time it could result in my prescription being delayed and it will affect my treatment plan.

25. I understand that it is illegal to give away or sell my medication – this is diversion.  If I do this, my treatment may require referral to a higher level of care, and/or a change in medication based on the doctor’s evaluation or could result in immediate discharge from the clinic.  

26. In the event that I am unable to fulfill my financial obligation, the clinic reserves the right to withdraw medical services. If I deem the situation emergent, I will dial 911 or report to my local emergency room. If I would like to seek alternative medical care, the clinic will provide appropriate referrals.

27. The goal of opioid treatment is stabilization of functioning.

28.  I have received information about my patient’s right and facility’s grievance procedure.  

29.  I understand that “exceptions” can happen on rare occasions, I WILL NOT have false expectations of the “exception” becoming a “normal treatment” for me.

30.  I understand that if I have an unpaid balance, the office will hold me accountable for the balance before continuing my treatment. 

    1. If you are not sure if you have a balance, please ask one of our staff. 

31. I have received a copy of the facility’s rules and regulations along with a copy of my rights and responsibilities.

32.  I understand that I may choose to withdraw from or be maintained on the medication as I desire unless medically contraindicated.

33. I understand that in regular intervals and in full consultation, the physician will discuss my present level of function, course of treatment and future goals.