Form Patient Notice Patient Notice Patient Notice

Sample Patient Notice

[Date]

[Patient name]

[Patient Address]

Dear [Patient name],

This letter is written confirmation that I must discontinue treating you with buprenorphine as of [Date]. I must take this action in order to bring my practice into alignment with federal regulations which dictate the limit on the number of patients I must treat at one time to be 100 as of that date. I am committed to making every effort to assist you in continuing your treatment.

In my opinion, your condition requires ongoing medication assisted treatment and behavioral services such as counseling.

At this time I can offer to transition you to medication assisted treatment not subject to this regulation: extended-release injectable naltrexone. Please schedule an appointment with me at your earliest convenience to discuss whether this option is right for you.

I urge you consider placing yourself under the care of another health care professional or treatment program to continue your medication assisted treatment. Please visit www.findtreatment.SAMHSA.gov to identify a local treatment provider. I will be pleased to provide a copy of your records to your new health care provider upon receiving an appropriate authorization signed by you.