Compliance Attestation Form | PursueCareRx Pharmacy

I affirm that I am prescribing buprenorphine as part of an appropriate individualized treatment plan for the patient indicated in this affidavit. I further confirm that I am not exceeding the patient limits under by DEA waiver to prescribe buprenorphine, nor violating state or federal regulations in any other way. I understand that PursueCareRx reserves the right to refuse any prescription that, in its sole discretion, does not meet customary best practices for treatment of Opioid Use Disorder via Medication-Assisted Treatment, and/or is suspected for diversion or misuse.

General Assessment: (Y=Yes, N=No, N/A if not applicable; for patient treatment informational purposes; absolute indications not necessarily required for dispensing, but may require further consultation between pharmacy and provider, and/or supporting documentation; please attach any supporting treatment plan documentation or notes that may be required to further explain any answer)

Absence of recent abuse of drugs (opioid, narcotic, or non-narcotic), including alcohol*

Yes
No
N/A

Regularity of clinic/treatment attendance and/or general adherence to treatment plan*

Yes
No
N/A

Evaluation completed by a licensed Drug and Alcohol counselor, therapist, or other qualified individual to determine the recommended level of care?*

Yes
No
N/A

Regularity of counseling/therapy at generally accepted intervals*

Yes
No
N/A

Stability of the patient's home environment and social relationships*

Yes
No
N/A

Length of time in comprehensive maintenance treatment significant (if applicable)*

Yes
No
N/A

Assurance that take-home medication can be safely stored within the patient's home*

Yes
No
N/A

If prescribing buprenorphine without naloxone (Subutex and generic): (please provide explanation or supporting records).

History of stability with Subutex or similar*

Yes
No
N/A

Trouble tolerating buprenorphine-naloxone combination medications*

Yes
No
N/A

Trouble affording buprenorphine-naloxone combination medications*

Yes
No
N/A

Contraindication Identified contraindication to buprenorphine-naloxone combination medications*

Yes
No
N/A

Explanation or Supporting Records

Presence of “Red Flag” Behaviors:

Use of buprenorphine-naloxone combination medication (Suboxone) rejected by patient*

Yes
No
N/A

Consecutive positive toxicology screens during active treatment*

Yes
No
N/A

Erratic ability to keep appointments and/or adhere to treatment plan*

Yes
No
N/A

Multiple prescribers prior to my treatment or during my treatment*

Yes
No
N/A

Known instances of prescription forgery*

Yes
No
N/A

Requests for early refills*

Yes
No
N/A

Lost prescriptions*

Yes
No
N/A

Sudden request for dose increases in a previously stabilized or compliant patient*

Yes
No
N/A

Close acquaintances (significant others, spouse, friends) with opioid dependence not in treatment*

Yes
No
N/A

Prevention:

Prescriber requires toxicology screens at every appointment or at generally accepted regular intervals (includes buprenorphine, alcohol, and other drugs of abuse)*

Yes
No
N/A

If screens occur on site, prescriber office does NOT allow carry-in items (purses, backpacks) into the bathroom where such screens occur*

Yes
No
N/A

If diversion is suspected with population treated, office takes customary measures to prevent falsifying collection samples*

Yes
No
N/A

Prescriber office monitors premises for signs of diversion*

Yes
No
N/A

Prescriber conducts accountability checks such as random medication counts and random screens*

Yes
No
N/A

Prescriber limits medication supply for patients who are unstable or suspected of diversion*

Yes
No
N/A

Patient has been advised of appropriate medication storage and preventing misuse by others*

Yes
No
N/A

Patient has been advised of risks of medication(s) and consented to treatment*

Yes
No
N/A

I am prescribing Maintenance Monotherapy Buprenorphine not to exceed 16mg per day to this patient as” medical necessity”, the patient has reported to me a past experience with allergic response that may include but is not limited to throat constriction, mouth blister/sores, skin hives, severe headaches and other such described allergic manifestations. In my medical judgement there is a potential danger of allergic response together with the potential for patient non-compliance with combination therapy (i.e. suboxone) that may lead to a life-threatening situation or relapse to underlying opioid addiction.

Do you intend to use Maintenance Monotherapy Buprenorphine in accordance with the statement above?*

Yes
No

Brief Explanation of Treatment Plan:*

Today's Date*