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)
If prescribing buprenorphine without naloxone (Subutex and generic): (please provide explanation or supporting records).
Presence of “Red Flag” Behaviors:
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.