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The purpose of this agreement is to outline the terms and requirements of being a patient at our clinic.  These guidelines are designed to provide each patient with the best possible patient experience. Please also review our other policies regarding your privacy and reasons for termination.

  • I will regularly see my primary care provider who is responsible for my general health needs.

  • I will treat all clinic staff with respect and conduct myself appropriately in the office. 

  • I will be honest about my pain levels and use of medications.

  • I will comply with the treatment plan that my provider and I partnered to establish, including referrals to specialists, diagnostic testing, psychological testing/therapy, etc.

  • I understand that if the my provider permits me to receive my counseling through an outside counselor (i.e., one not at Merkava Treatment Center), then I am responsible for providing documentation that I am in compliance with the counseling requirement of the comprehensive therapeutic program.

  • I understand and accept the risks and side effects associated with the use of prescription medications.  I will read all drug inserts provided by the pharmacy, and ask any questions of my provider if I am unclear about the risks and side effects associated with any prescribed medications.

  • I agree to keep and be on time to all my appointments. If I am less than 30 minutes late I understand that I can be seen at the end of the day or sooner if time permits. If I am more than 30 minutes late to my appointment I will automatically be rescheduled for a future date and charged a missed appointment fee.

  • If I fail to attend a scheduled appointment or cancel my appointment less than 24 hours prior to the appointment time, three times in a twelve month period, I understand that I will be discharged from the clinic.

  • I agree NOT to sell, share, or give away any of my medication to another person. I understand that such mishandling of my medication is a serious violation and could result in my treatment being terminated.

  • I agree that the medication prescribed for me is my responsibility and that I am required to keep it in a safe and secure location, preferably in a lock box. I understand that lost or stolen medication will NOT be replaced regardless of the circumstances. I understand that the policy of Merkava Treatment Center is: NO EARLY REFILLS.

  • I agree that prescribed medications will be provided to me only at my regular office visits. I further understand that a missed appointment may result in my not being able to obtain my medication/prescription until the next regularly scheduled appointment.

  • I agree to abstain from ALL opioids, benzodiazepines, methamphetamine, heroin, cocaine, illicitly obtained substances, and other substances of abuse while taking Suboxone. Failure to comply may result in termination from the treatment program at provider’s discretion.

  • I agree to provide urine specimens at every office visit, and in addition to provide random urine samples upon request of the medical provider. I understand that a positive urine drug screen will result in confirmatory testing from an outside laboratory at my expense.

  • I agree to appear for a random pill count upon request of the medical provider. I understand that failure to provide a random urine specimen or failure to appear for a random pill count will be considered grounds for discharge from the treatment program.

  • I agree to adhere to the clinic payment policy.

  • I understand that violations of any of the above may be considered grounds for termination of treatment.

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