Data Elements for Referal to Primary Care for Maintaince Buprenorphine Therapy

Patient Information
Patient Name: ______Patient DOB: ____ /____ /_____ Patient Address: ______

Patient Phone: ( ) ______- ______

Name of Emergency Contact: ______Phone: ( ) ______- ______

Continuing Care Provider: Phone ( ) -

Insurance Information

Type of Insurance: ______

Insurance Number:

Name of MCO:

Dates of Authorization for Suboxone Medication: // to //

Please attach copy of notification form or authorization formif available

Transfer Criteria

Patient Meets the Following Transfer Criteria (check all that apply):

 No withdrawal symptoms

 Minimal or no side effects of buprenorphine

 No longer has uncontrollable cravings for opioid agonists

 Compliant with independent medication administration for at least 2 weeks

 Compliant with counseling and treatment appointments

Last toxicology test is negative for opioid use

Patient tested positive for buprenorphinewithin the last 30 days

Drug Testing Results

Attach LASTurinalysis/tox screenresults and buprenorphine UA/dip stick resultsto this form

Date of Last Tox Screen: ____ / ____ / ______

Drugs Detected in Last Tox Screen:

None  Cocaine  Marijuana  Benzodiazepines  Alcohol  Analgesics  Stimulants  Others: ______

Medical History

Intake physical and/or copy of latest H&P attached: Yes No 

If NO, report medical history and current diagnoses:______

______

______

Medications: ______

Allergies: ______

Psychiatric History

None  Bipolar Disorder  Major Depression  OCD  Schizophrenia  PTSD 

Anxiety Disorder  Other: ______

Medications: ______

PCP Transfer Orders

Buprenorphine Prescription: ______mg of buprenorphine ______time(s) per day

Date of Last Rx: ____ / ____ / _____

Number of Tablets Prescribed in Last Rx: ______

DatePatient Will Run Out of Medication: ____ / ____ / ______

Recommended Follow-Up:

Frequency of Follow-Up PCP Visits: ______

FrequencyDuration of Counseling Sessions at Our Substance Abuse TreatmentProgram: ______

Signatures

Date: ____ / ____ / ______

Phone Number of Referring Physician: ( ) ______- ______

Name of Referring Physician (please print): ______

Signature of Medical Staff completing paperwork:______

Phone Number of Treatment Counselor: ( ) -

Name of Treatment Counselor (please print):

Signature of Treatment Counselor:

Client Signature:Date:

(BHCA 3/23/11)

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