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					                                                                Name ___________________________________
                                                                   Medical Record Number ________________

During your treatment at Kalamazoo Community Mental Health and Substance Abuse Services (KCMHSAS), you
may receive medication to help treat your Opiate or Alcohol Dependence to aid in your early recovery and
managing withdrawal and cravings. These medications include, but are not limited to Campral (acamprosate),
Suboxone (buprenorphine) and Vivitrol (naltrexone). These medications are controlled substances regulated by
State and Federal authorities. It is important that you understand the guidelines that we have in place to prevent
their misuse. It is also important for you to understand how these medications fit into your overall treatment plan
and our philosophy of care in the use of medications to treat substance use disorders.

First, it is important that you understand our philosophy of care in the use of Suboxone, Campral, and Vivitrol.
Within our practice, these medications are used on a short term basis (several weeks to several months) in the
treatment of Opiate and Alcohol Dependence. The goal of these medications is to allow you to initiate your
recovery while experiencing fewer effects of withdrawal and cravings. These medications, taken as prescribed, are
generally safe, have a low risk of overdose, and are one piece to you being able to sustain your recovery. It is our
expectation that while taking these medications, you are engaging in non-medication therapy as well, such as
outpatient therapy, case management, and 12-step or community-based recovery programming. Since these
medications are available on a time-limited basis (for example, most insurance companies, including Medicaid, only
authorize Suboxone for 12 weeks initially), becoming involved in these other treatments are crucial to your recovery

Please sign the agreement below to document your understanding of and agreement with these requirements.

   I understand that if I am receiving medications to treat my substance use disorder, I am expected to inform
    other physicians who are also involved in my care that I am on these medications from KCMHSAS.

   The pharmacy I will use to fill my prescription of addiction medications is ______________________________.
    I will not use any other pharmacy to fill my prescription. I will notify my prescriber if my pharmacy changes. I
    understand that I am responsible for any co-pays or charges beyond that which my insurance covers for my
    medication. I understand that it is a federal offense to alter a prescription in any way.

   I understand that I am responsible for my prescription and for my medication once filled. We have a no
    replacement policy unless there is a valid clinical reason, which is to be determined by your physician.

   I will make every attempt to remain alcohol and drug free while I am medications to treat me addiction, and that
    if I do use I will inform my physician so that they may take that into consideration in my treatment plan.

   I am aware that I may be asked to submit a urine or blood sample in the course of my treatment to check to see
    if I have taken other substances. I understand that continuing to receive medication is contingent upon my
    willingness to complete labs as ordered.

   I understand that if I do not follow these guidelines, I may be discharged from the practice of KCMHSAS,
    without any warning, or the doctors at KCMHSAS may refuse to prescribe medications to treat my substance
    use disorder.

                                SIGNATURE                                                               DATE

                                 WITNESS                                                                DATE

                            418 West Kalamazoo Avenue, Kalamazoo, MI 49007
                          Phone: (269) 553-7037           Fax: (269) 553-7106

                                                                                                                          Effective Date: 11/01/08
                                                                                                         Authorizer: Chief Medical Director / QLT
                                                                                      Application: KCMHSAS Staff & Contract Providers (MH & SA)
                                                                                                                                 Supersedes: NEW
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