GA Randy Durbin Suboxone Patient Information Sheet 2014-2025 free printable template

Randy E. Durbin, D.O., P.C. 800 Old Dawson Village Rd., Suite 020 Watsonville, GA 30534 PHONE: 7062167188 FAX: 18558842774 Patient Information Sheet Today's Date: / / Patient Name: Date of Birth:

How to fill out GA Randy Durbin Suboxone Patient Information

How to fill out GA Randy Durbin Suboxone Patient Information Sheet

1. Start with your personal information: Enter your full name, date of birth, and contact details at the top of the form.
2. Fill in your health insurance information: Include your insurance provider's name, policy number, and any group number if applicable.
3. Provide your medical history: Detail any current medications, allergies, and previous treatments related to substance use.
4. Complete the substance use section: Indicate your history of substance use, including types of substances used and duration.
5. Signature and date: Sign the form to verify that the information provided is accurate and date the form.

Who needs GA Randy Durbin Suboxone Patient Information Sheet?

1. Individuals seeking treatment for opioid dependence or addiction.
2. Patients who are starting a Suboxone program with Dr. Randy Durbin.
3. Those who require a structured assessment of their substance use history.

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What is GA Randy Durbin Suboxone Patient Information Sheet?

The GA Randy Durbin Suboxone Patient Information Sheet is a document used to provide essential information about Suboxone treatment, which is a medication-assisted therapy for opioid addiction.

Who is required to file GA Randy Durbin Suboxone Patient Information Sheet?

Healthcare providers administering Suboxone treatment are required to file the GA Randy Durbin Suboxone Patient Information Sheet.

How to fill out GA Randy Durbin Suboxone Patient Information Sheet?

To fill out the GA Randy Durbin Suboxone Patient Information Sheet, follow the instructions provided in the form, ensuring all personal, medical, and treatment-related information is accurately completed.

What is the purpose of GA Randy Durbin Suboxone Patient Information Sheet?

The purpose of the GA Randy Durbin Suboxone Patient Information Sheet is to document patient information and treatment plans, ensuring compliance with regulations and facilitating effective care.

What information must be reported on GA Randy Durbin Suboxone Patient Information Sheet?

The information that must be reported includes patient demographics, medical history, treatment details, and progress notes related to Suboxone therapy.