Treatment Providers. The MCOP shall contract with at least the minimum number of Ohio Department of Mental Health and Addiction Services (OhioMHAS)-certified SUD treatment providers identified in Table 4
Treatment Providers. As required by IPRP, I agree to undergo a complete medical, psychiatric and/or substance abuse evaluation at an IPRP approved treatment provider, and/or to provide information regarding the evaluations and treatment plans, including medication used to treat opioid use disorder or other disabilities, by my current treatment providers. If treatment is recommended, I agree to follow all treatment recommendations to the extent that they do not conflict. I also understand and agree that any and all costs related to treatment (Residential, PHP, IOP, aftercare, and individual therapy) are solely my responsibility. I agree to the following: Facility Name: Facility Address: COPY Contact Person: Phone Number: Level of Treatment: I will ensure that my treatment provider(s) will submit weekly updates [Inpatient only] and quarterly reports while in treatment, as well as a final discharge summary. If applicable, the quarterly reports must include copies of drug screen results demonstrating compliance with any oral Naltrexone prescriptions or Vivitrol injections. COPY Phone Number:
Treatment Providers. As required by IPRP, I agree to undergo a complete medical, psychiatric and/or substance abuse evaluation at an IPRP approved treatment provider, and/or to provide information regarding the evaluations and treatment plans, including medication used to treat opioid use disorder or other disabilities, by my current treatment providers. If treatment is recommended, I agree to follow all treatment recommendations to the extent that they do not conflict. I also understand and agree that any and all costs related to treatment (Residential, PHP, IOP, aftercare, and individual therapy) are solely my responsibility. I agree to the following: Facility Name: Facility Address: Contact Person: Phone Number: Level of Treatment: I will ensure that my treatment provider(s) will submit weekly updates [Inpatient only] and quarterly reports while in treatment, as well as a final discharge summary. If applicable, the quarterly reports must include copies of drug screen results demonstrating compliance with any oral Naltrexone prescriptions or Vivitrol injections. If an Addiction Physician (physician certified in addiction medicine) is recommended, I agree to see: Physician Name: Phone Number: Facility Name: Facility Address: I will ensure my Addiction Physician will submit quarterly reports as well as a final discharge summary. If a Psychiatrist is recommended, I agree to see: Psychiatrist Name: Phone Number: Facility Name: Facility Address: I will ensure my Psychiatrist will submit quarterly reports as well as a final discharge summary. If Individual Counseling is recommended, I agree to see: Counselor Name: Phone Number: Facility Name: Facility Address: I will ensure my Individual Counselor will submit quarterly reports as well as a final discharge summary. If any treatment provider(s) or physician(s) determine I am not chemically free from any prohibited substances, have been non-compliant with the RMA or that I am unable, for any reason, to practice nursing safely, they will immediately notify IPRP and appropriate steps will be taken. I understand that the consequences for failure to comply with treatment plans/recommendations may result in action being taken against my file including but not limited to unsuccessful discharge from the program, being reported to the Indiana State Board of Nursing and/or the Indiana Office of the Attorney General.
