1. Purpose of Treatment
I understand that I am being offered treatment with Buprenorphine for opioid use disorder during pregnancy. Buprenorphine can reduce withdrawal symptoms and cravings, improving both my health and the health of my baby. Treatment is most effective when combined with counseling, behavioral therapy, and prenatal care.

2. Potential Risks and Benefits
Benefits:
    • Reduction of opioid withdrawal symptoms
    • Reduced risk of relapse
    • Potential improvement in maternal and fetal health outcomes

Risks:
    • Possible side effects including nausea, constipation, headache, and drowsiness
    • Neonatal Abstinence Syndrome (NAS) in the newborn
    • Unknown long-term effects on the child

I understand that abrupt discontinuation of opioids during pregnancy can be harmful to me and my baby. I have been informed of alternative treatments and understand that my decision to start or continue Buprenorphine is voluntary.

3. Coordination of Care
I consent to the sharing of my medical information with my prenatal care provider and other healthcare professionals involved in my care. Coordination between my OB/GYN and my Buprenorphine treatment provider is essential for safe treatment.

OB/GYN Information

4. HIPAA Release of Information
I authorize my Buprenorphine treatment provider to request, receive, and review my medical records from my OB/GYN for the purpose of coordination of care related to my Buprenorphine treatment during pregnancy.

This authorization includes, but is not limited to, the release of:
    • Prenatal records
    • Lab results
    • Imaging reports
    • Medication and prescription history
    • Any other relevant medical information necessary for safe treatment

I understand that:
    • This authorization is voluntary and I may revoke it in writing at any time, except to the extent action has already been taken in reliance on it.
    • My medical records may contain sensitive information.
    • The information disclosed may be re-disclosed by the receiving provider, but federal privacy laws may no longer protect it.

Expiration: This authorization will expire one year from the date signed, unless revoked in writing.

5. Patient Responsibilities
I agree to:
    • Attend scheduled appointments with my treatment provider
    • Take Buprenorphine exactly as prescribed
    • Notify my treatment provider of any changes in my health or medications
    • Inform my OB/GYN about my Buprenorphine treatment

6. Consent
I have had the opportunity to ask questions about Buprenorphine treatment, including risks, benefits, and alternatives. All my questions have been answered to my satisfaction. By signing below, I voluntarily consent to treatment with Buprenorphine while pregnant and authorize communication with my OB/GYN, including the release of medical records as described above.

I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.