Page 1 of 2

BUPRENORPHINE AND BUPRENORPHINE/NALOXONE PRIOR AUTHORIZATION REQUEST FORM

This form is for authorization of prescription drug benefits only and must be COMPLETELY filled out.

GENERAL INFORMATION
Patient
Name Tara Wright
Patient’s
Home Address 12315 U.S. 278
City State Zip
Beaverton AL 35544
Date of Birth
1 0 1 0 1 9 7 8
Contract Number b e g 8 4 1 2 0 8 9 7 8
(mm/dd/yyyy) (include prefix)

PRESCRIBER INFORMATION
Prescriber
Name adnan khan
Practice
Address 3415 S Sepulveda Blvd Suite 1250
City State Zip
Los Angeles CA 90034
Office Office
Phone (800) 799-6101 Fax (888) 777-1921
Practice Type PCP
X Specialty: physician
___________________________________ National Provider Indentifier (NPI) 1 1 8 4 0 1 0 6 1 3

SECTION I: TREATMENT INFORMATION (Please complete for all requests.)

Suboxone® X Subutex® Bunavail® 8MG
Zubsolv® Dose: ________ See attached sheet.
Directions: ___________________ [1]
______________________ Total Quantity:90 Tablets
________
F11.20
Diagnosis Code: ______________________________ Data 2000 Waiver ID (“X” DEA number): _________________________________
®
Please complete the following for Subutex requests only: Is the member pregnant? Yes X No If yes, anticipated date of delivery: ___________________
Does the member have a documented allergic reaction or intolerance to naloxone? X Yes No If yes, provide medical records documenting the reaction.
If you answered “No” to the two questions above, what is the medical necessity for prescribing Subutex®, rather than buprenorphine/naloxone, for this member.

SECTION II: (Please complete this section for induction and stabilization authorization requests only.)
Please check all applicable criteria and attach supportive documentation as to why continuation of therapy is necessary.
Prescriber maintains current informed consent signed by the prescriber and patient.
Prescriber has verified that the patient is currently not taking or will discontinue use of an opioid medication and/or addictive drug (including problematic alcohol and/or
benzodiazepine use) prior to beginning treatment with requested agent.
Prescriber attests that patient is currently enrolled in an ongoing outpatient drug addiction treatment/counseling program or has agreed to seek enrollment within the first
2 months of treatment with requested agent.
Prescriber has attached an initial treatment plan including current baseline urine drug screen and documentation of medication history review.
Supportive documentation and clinical chart notes are required for review.

SECTION III: (Please complete for maintenance therapy authorization requests only.)
X Prescriber maintains current informed consent signed by the prescriber and patient.
X Physician certifies that they meet the requirements under DATA and have not exceeded the maximum number of patients allowed.
X Patient has been through induction and stabilization therapy and now seeks medication for maintenance therapy for treatment of a confirmed diagnosis of active opioid
dependence. Consistent use of requested agent since previous authorization will be verified prior to approval.
X Prescriber has submitted a current treatment plan which includes a medication history review and the most recent drug screen indicating patient is free from illicit drug use.
Supportive documentation and clinical chart notes are required for review.
X Prescriber has reviewed the patient’s records in the states prescription drug monitoring program (PDMP) to confirm that the patient is not diverting medication.
X The patient continues to be enrolled in an outpatient drug addiction treatment /counseling program and has been compliant with all elements of the medical treatment
plan or rationale has been submitted as to why patient no longer needs to continue drug addiction treatment.
X Documentation provided of anticipated duration of treatment, plan for drug taper or barriers to drug taper at this time.

PRESCRIBER SIGNATURE
I certify this information is complete and
07/09/2024
correct to the best of my knowledge. Prescriber Signature Date
Please attach any additional medical justification.

SUBMISSION FAX You may fax the signedand completed form to MAIL You may mail the signed and completed form to:
INSTRUCTIONS Pharmacy Review at: Pharmacy Review
PRV20535BP-2206
1-866-606-6021 Post Office Box 529 • Auburn, AL 36381
 Page 2 of 2

--------------------------------------------------------------------------------
Patient: Tara Wright DOB: 10/10/1978
Member: beg841208978
Sent: 07/09/2024
--------------------------------------------------------------------------------

NOTES
[1] Directions
1 Tablet Sublingual, 3 times daily for 30 days

[2] Explanation
medically necessary for the patient achieve the maximum function. This is prescribe as a continuation for
therapy.
Medication name: Diflucan 100MG PO Tablet
Status: Sent
Prescriber: Adnan Khan, DO
Dispense amount: 7 Tablets
Quantity (and dosage): 1 TABS
Directions: 1 Tablet, Daily for 7 days
Frequency: QD for 7 days
Refills: 0
Pharmacy: Family Health Pharmacy
NCPDP ID: 0114164
Phone: 2056989770
Street: 55298 Highway 17
City: Sulligent
State: AL
Zip: 35586
Created: Jul 09 2024

Medication name: Buprenorphine HCl 8MG SL Tablet Sublingual

Status: Sent
Prescriber: Adnan Khan, DO
Dispense amount: 90 Tablets
Quantity (and dosage): 1 SUBL
Directions: 1 Tablet Sublingual, 3 times daily for 30 days
Frequency: TID for 30 days
Refills: 0
Pharmacy: Family Health Pharmacy
NCPDP ID: 0114164
Phone: 2056989770
Street: 55298 Highway 17
City: Sulligent
State: AL
Zip: 35586
Created: Jul 09 2024

Patient records page 3 of 21

Medication name: Buprenorphine HCl 8MG SL Tablet Sublingual
Status: Sent
Prescriber: Adnan Khan, DO
Dispense amount: 90 Tablets
Quantity (and dosage): 1 SUBL
Directions: 1 Tablet Sublingual, 3 times daily for 30 days
Frequency: TID for 30 days
Refills: 0
Pharmacy: Family Health Pharmacy
NCPDP ID: 0114164
Phone: 2056989770
Street: 55298 Highway 17
City: Sulligent
State: AL
Zip: 35586
Created: Jan 29 2024

Past visits
Visit: Jul 09 2024, 7:50am

Visit type: Addiction Treatment - $99 - Suboxone / MOUD

Visit method: Phone
Visit status: Complete
Provider: Dr. Adnan Khan

Visit note

Saved on: Jul 09 2024, 8:01am

Today's visit was conducted via telehealth. I have verified the patient’s identity. The patient has
identified their physical location, including their city and state. I have disclosed my identity and
credentials to the patient. The patient is a 45-year-old female with OUD taking MOUD. Pt’s last full
agonist opioids were in: 2021 Pt's last visit was on 6/9, doing well overall and reports taking the
medication as directed. She is looking forward to going on a kayaking trip soon. As for her MOUD, she
is adherent to Subutex and was most recently prescribed Subutex 8mg tab, 1 tab three times daily.
She denies any cravings and withdrawal symptoms. Pt has a good support system, denies currently
attending counseling or groups. Most recent buprenorphine script dispensed (on AL PDMP) 6/12/2024.
PMH: OUD, degenerative disc, ulcerative colitis, spinal fusion, levoscoliosis Meds: Subutex, Linzess,
Zofran, Mucinex. Allergies: Benadryl, naloxone. Social: Benefits verification at CVS. Pt re-iterates that
she does not partake in the consumption of alcohol, use of non-prescribed drugs or the use of BZDs.
General: alert, no acute distress Respiratory: speaking in full sentences, no audible wheezing or
coughing. Psychiatric: answers questions appropriately, oriented to person, place, and time F11.21
Stable. Continue Subutex. Rx Diflucan for a yeast infection. Encourage CBT. Follow up in 1 month.
Patient records page 6 of 21
PDMP reviewed and appropriate. As per Alabama state law, a urine drug screen has been completed
on 6/20/2024 for this patient for her required drug screening test, which is every 3 months during
treatment with MOUD. UDS positive for only buprenorphine.

ICD-10 codes

F11.20

Opioid dependence, uncomplicated

Visit: Jun 10 2024, 12:50am

Visit type: Addiction Treatment - $99 - Suboxone / MOUD

Visit method: Phone
Visit status: Complete
Provider: Dr. Adnan Khan

Visit note

Saved on: Jun 10 2024, 12:47am

Today's visit was conducted via telehealth. I have verified the patient’s identity. The patient has
identified their physical location, including their city and state. I have disclosed my identity and
credentials to the patient. The patient is a 45-year-old female with OUD taking MOUD. Pt’s last full
agonist opioids were in: 2021 Pt's last visit was on 5/3, doing well overall and reports taking the
medication as directed. She states that she currently has a kidney infection, was given antibiotics
in the ER and is currently taking antibiotics now. As for her MOUD, she is adherent to Subutex and
was most recently prescribed Subutex 8mg tab, 1 tab three times daily. She denies any cravings and
withdrawal symptoms. Pt has a good support system, denies currently attending counseling or groups.
Most recent buprenorphine script dispensed (on AL PDMP) 5/15/2024. PMH: OUD, degenerative
disc, ulcerative colitis, spinal fusion, levoscoliosis Meds: Subutex, Linzess, Zofran, Mucinex. Allergies:
Benadryl, naloxone. Social: Benefits verification at CVS. Pt re-iterates that she does not partake
in the consumption of alcohol, use of non-prescribed drugs or the use of BZDs. General: alert, no
acute distress Respiratory: speaking in full sentences, no audible wheezing or coughing. Psychiatric:
answers questions appropriately, oriented to person, place, and time F11.21 Stable. Continue Subutex.
Encourage CBT. Follow up in 1 month. PDMP reviewed and appropriate. As per Alabama state law, a
urine drug screen has been ordered on 6/9/2024 for this patient for her required drug screening test,
which is every 3 months during treatment with MOUD.

ICD-10 codes

F11.20

Opioid dependence, uncomplicated

Patient records page 7 of 21

Visit: May 04 2024, 10:31am

Visit type: Addiction Treatment - $99 - Suboxone / MOUD

Visit method: Phone
Visit status: Complete
Provider: Dr. Kyle Meggison

Visit note

Saved on: May 04 2024, 2:29pm

Location of today’s appointment: Telehealth
I have verified the patient’s identity.
The patient has identified their physical location, including city and state.
I have disclosed my identity and credentials to the patient.
I have obtained the patient’s consent for the use of telehealth.

45 yo female with OUD taking MOUD.

Pt’s last full agonist opioids were in 2021

Pt is adherent to the Suboxone as prescribed. Pt is taking Subutex tid 8mg. Pt denies cravings or
withdrawal symptoms at the present time. Pt is not currently attending NA, other self-help groups
and/or psychotherapy to aid in recovery. Most recent buprenorphine script filled on 4/3/24 (per the
PDMP)

PMH: oud
All current prescription Meds: Subutex, linzess
Allergies: morphine, naloxone, benadryl
Adverse drug reaction (ADR) to sublingual naloxone: itching
Social: noncontributory
Current use of alcohol, benzodiazepines, or other non-prescribed medications/drugs: no

General: alert, no acute distress

Respiratory: speaking in full sentences, no audible wheezing or coughing.
Psychiatric: answers questions appropriately, oriented to person, place, and time

F11.21 (opioid use disorder, in remission)

Stable. Continue Suboxone at the same dose. Recommend/Continue self help groups/individual
psychotherapy.
Follow up in 1 month.
PDMP reviewed and appropriate.

ICD-10 codes

F11.21

Opioid dependence, in remission

Patient records page 8 of 21

Visit: Apr 04 2024, 4:00am

Visit type: Addiction Treatment - $99 - Suboxone / MOUD

Visit method: Phone
Visit status: Complete
Provider: Dr. Adnan Khan

Visit note

Saved on: Apr 04 2024, 3:59am

Today's visit was conducted via telehealth. I have verified the patient’s identity. The patient has
identified their physical location, including their city and state. I have disclosed my identity and
credentials to the patient. The patient is a 45-year-old female with OUD taking MOUD. Pt’s last full
agonist opioids were in: 2021 Pt's last visit was on 3/2, doing well overall and reports taking the
medication as directed. She is adherent to Subutex and was most recently prescribed Subutex 8mg
tab, 1 tab three times daily. She denies any cravings and withdrawal symptoms. Pt has a good support
system, denies currently attending counseling or groups. Most recent buprenorphine script dispensed
(on AL PDMP) 3/4/2024. PMH: OUD, degenerative disc, ulcerative colitis, spinal fusion, levoscoliosis
Meds: Subutex, Linzess, Zofran, Mucinex. Allergies: Benadryl, naloxone. Social: Benefits verification
at CVS. Pt re-iterates that she does not partake in the consumption of alcohol, use of non-prescribed
drugs or the use of BZDs. General: alert, no acute distress Respiratory: speaking in full sentences, no
audible wheezing or coughing. Psychiatric: answers questions appropriately, oriented to person, place,
and time F11.21 Stable. Continue Subutex 8 mg tab, 1 tab three times daily. Encourage CBT. Follow
up in 1 month. PDMP reviewed and appropriate. As per Alabama state law, a urine drug screen has
been ordered on 4/3/2024 for this patient for her required drug screening test, which is every 3 months
during treatment with MOUD.

ICD-10 codes

F11.20

Opioid dependence, uncomplicated

Visit: Mar 03 2024, 5:34am

Visit type: Addiction Treatment - $99 - Suboxone / MOUD

Visit method: Phone
Visit status: Complete
Provider: Dr. Eslam Mohamed

Visit note

Saved on: Mar 03 2024, 5:31am

Subjective
HPI:

Patient records page 9 of 21

The patient reports stable progress since the last visit. Patient has been consistently taking Subutex
as prescribed for the management of opioid use disorder. Denies any new symptoms or concerns.
Reports stability in mood and energy levels, no complaints of adverse effects.
Last full dose Opioid agonist: "14 years ago"

Objective

PMHX: OUD, ibs

MEDS: Subutex, linzess, vitamin b and d
Allergies: Naloxone/suboxone- swelling and sleepiness
Current dosage: 8 mg Subutex tablets
Three times a day

Physical Exam:
General: alert, no acute distress, hearing intact to conversation
Respiratory: speaking in full sentences, no audible wheezing or coughing.
Psychiatric: answers questions appropriately, oriented to person, place, and time

I have conducted a thorough review of the Prescription Drug Monitoring Program (PDMP). Here is a
summary of my findings:
Last refill For Subutex: 1/29/2024
Other:

Laboratory Results:
Urine drug screen: pending

Assessment
F11.2 Opioid Use Disorder
Patient appears to be stable on the current Subutex regimen.
No evidence of substance abuse.
Compliance with treatment plan observed.
No acute issues noted during the examination.

Plan

- Refill Subutex prescription to pharmacy on file.

- Schedule follow-up appointment in 4 weeks or sooner.
- Reinforce importance of medication compliance.
- Encourage continued engagement in counseling or support groups.

_____________________________________
- Telehealth appointment; patient previously consented.
- Verified patient's identity.
- Patient provided current physical location (city and state).
- I disclosed my identity and credentials to the patient.

ICD-10 codes

F11.20

Opioid dependence, uncomplicated

Patient records page 10 of 21

Patient instructions

Saved on: Mar 03 2024, 5:31am

Congratulations on taking steps towards your recovery with Suboxone/subutex treatment. This med-
ication can help you manage withdrawal symptoms, cravings, and ultimately support your journey to
a healthier, drug-free life.

Suboxone/subutex is a medication that contains buprenorphine and naloxone, and it is used to treat
opioid dependence. It works by binding to the same receptors as opioids, but with less euphoria and
withdrawal symptoms. Suboxone is taken as a sublingual film that dissolves under the tongue

1. Adhere to your Suboxone schedule as prescribed; contact your provider with concerns.
2. Administer under the tongue or inside the cheek, avoiding eating or drinking for 10 minutes.
3. Avoid alcohol and sedatives to prevent complications.
4. Seek immediate medical help for severe side effects.
5. Store securely, away from children, at room temperature.
6. Attend follow-up appointments for monitoring and adjustments.
7. Consult your provider if pregnant or breastfeeding.
8. Promptly take missed doses but avoid doubling up.
9. Seek support from trusted websites like SAMHSA and NIDA.

Visit: Jan 30 2024, 4:40am

Visit type: Addiction Treatment - $99 - Suboxone / MOUD

Visit method: Video
Visit status: Complete
Provider: Dr. Adnan Khan

Visit note

Saved on: Jan 30 2024, 4:46am

Today's visit was conducted via telehealth. I have verified the patient’s identity. The patient has
identified their physical location, including their city and state. I have disclosed my identity and
credentials to the patient. The patient is a 45-year-old female with OUD taking MOUD. Pt’s last full
agonist opioids were in: 2021 Pt is new to QuickMD and is looking for a new Subutex prescriber. Pt
is transferring from current prescriber (Dr Ruth Darr Snow, MD) due to transportation issues. Pt is
currently taking Subutex 8mg tab, 1 tab three times daily. Pt has been stable on Subutex for over a
year. Pt denies cravings and withdrawal symptoms. Pt has a good support system, denies currently
attending counseling or groups. Most recent buprenorphine script filled (on AL PDMP) 12/30/2023.
PMH: OUD, degenerative disc, ulcerative colitis, spinal fusion, levoscoliosis Meds: Subutex, Linzess,
Zofran, Mucinex. Allergies: Benadryl. Social: Benefits verification at CVS. Pt re-iterates that she does
not partake in the consumption of alcohol, use of non-prescribed drugs or the use of BZDs. General:
alert, no acute distress Respiratory: speaking in full sentences, no audible wheezing or coughing.
Psychiatric: answers questions appropriately, oriented to person, place, and time F11.21 Stable.
Continue Subutex 8 mg tab, 1 tab three times daily. UDS quarterly per Alabama state guidelines,
will follow up with her PCP on this and provide results. Encourage CBT. Follow up in 1 month. PDMP
reviewed and appropriate.

Visit note addendum

Patient records page 11 of 21

Written by: Dr. Adnan Khan
Saved on: Feb 14 2024, 4:20am
Addendum created to include allergy to naloxone.

ICD-10 codes

F11.20

Opioid dependence, uncomplicated

Intake forms
Suboxone/MOUD

Completed on: Jul 06 2024

Visit type: Suboxone / MOUD

Questions
Q1. In detail, what is the reason for your visit?
refill

Q2. When did you first become dependent on opioids?

i took ulttram per prescription before they became narcotic when they became narcotic i had a nurse
practitioner suggest suboxone and ive been on these since

Q3. When was the last time you took any opioids other than buprenorphine/Suboxone (street opioids
or prescribed)?
about 16 yrs ago on reg basis

Q4. Have you been prescribed buprenorphine/Suboxone in the past? If so when was the last dose?
subutex for 14 yrs

Q5. If you have been on buprenorphine/Suboxone in the past, which dose worked well for you?
3 daily 8mg

Q6. Are you taking any other drugs, including alcohol and marijuana, besides opioids? If so, which
ones?
no absolulately not; none marijuana swells my throat shut and i cant drink at all

Q7. Are you currently receiving counseling or attending any groups for addiction care?
Yes

Patient records page 12 of 21

Q8. Would you be interested in QuickMD Counseling Services?
No

Q9. What kind of support systems do you have at home?

husband kids extended family

Q10. What other medical problems do you have?

levorotoscoliosis, degenerative disc disease, spinal fusion surgery, ulcerative colitis, reynard syn-
drome, ü restless, leg syndrome

Q11. Which medications are you taking (prescribed or non-prescribed)?

vit d3 50,000 unit cap once week, vitamin b complex injection every weeks, lincess 300mg bid, subutex
8mg tid keflex 750 mg bid zofran

Q12. Do you have any allergies to medications? If yes, which ones?

naloxone morphine benadryl

Q13. What is your preferred pharmacy? Please enter pharmacy name and either phone number or
address.
family health pharmacy in sulligent Alabama 2056989770

Q14. How did you find about QuickMD?

Referred by a friend

Q15. Do you have a Primary Care Provider? If so, what is their name?
charles david rubley

Q16. If you have a primary care provider, what is their address and/or phone number?
2056987111

Q17. May we contact your primary care provider to coordinate care/referrals if needed?
yes

Q18. As part of your treatment and according to state regulations, you may be asked to undergo an
urine drug screenings. The results of drug screening are confidential and not shared with anyone
outside of QuickMD. You will not be dismissed from QuickMD care solely due to a positive drug screen.
Please choose "Yes" to confirm your understanding.
Yes

Q19. Please acknowledge that QuickMD does not participate with insurance and all costs associated
with medical services will be the direct responsibility of the patient.
I acknowledge that QMD does not participate in any insurance program.; I understand this visit is cash
pay and will not go through my insurance carrier.

Q20. In order to complete your upcoming visit, we must verify your identity. Please upload one image
that shows the front of your driver’s license.
DD2D83D2-A972-42C2-BF74-9EB657E816FD.JPG

Patient records page 13 of 21

Q21. In order to complete your upcoming visit, we must verify your identity. Please upload one image
that shows the back of your driver’s license.
DD2D83D2-A972-42C2-BF74-9EB657E816FD.JPG

Q22. In order to complete your upcoming visit, we must verify your identity. Please upload one image
that includes your face and ID.
DD2D83D2-A972-42C2-BF74-9EB657E816FD.JPG

Suboxone/MOUD

Completed on: Jun 09 2024

Visit type: Suboxone / MOUD

Questions
Q1. In detail, what is the reason for your visit?
refill

Q2. When did you first become dependent on opioids?

i took ulttram per prescription before they became narcotic when they became narcotic i had a nurse
practitioner suggest suboxone and ive been on these since

Q3. When was the last time you took any opioids other than buprenorphine/Suboxone (street opioids
or prescribed)?
about 16 yrs ago on reg basis

Q4. Have you been prescribed buprenorphine/Suboxone in the past? If so when was the last dose?
subutex for 14 yrs

Q5. If you have been on buprenorphine/Suboxone in the past, which dose worked well for you?
3 daily 8mg

Q6. Are you taking any other drugs, including alcohol and marijuana, besides opioids? If so, which
ones?
no absolulately not; none marijuana swells my throat shut and i cant drink at all

Q7. Are you currently receiving counseling or attending any groups for addiction care?
Yes

Q8. Would you be interested in QuickMD Counseling Services?

No

Q9. What kind of support systems do you have at home?

husband kids extended family

Patient records page 14 of 21

Q10. What other medical problems do you have?
levorotoscoliosis, degenerative disc disease, spinal fusion surgery, ulcerative colitis, reynard syn-
drome, ü restless, leg syndrome

Q11. Which medications are you taking (prescribed or non-prescribed)?

vit d3 50,000 unit cap once week, vitamin b complex injection every weeks, lincess 300mg bid, subutex
8mg tid keflex 750 mg bid zofran

Q12. Do you have any allergies to medications? If yes, which ones?

naloxone morphine benadryl

Q13. What is your preferred pharmacy? Please enter pharmacy name and either phone number or
address.
family health pharmacy in sulligent Alabama 2056989770

Q14. How did you find about QuickMD?

Referred by a friend

Q15. Do you have a Primary Care Provider? If so, what is their name?
charles david rubley

Q16. If you have a primary care provider, what is their address and/or phone number?
2056987111

Q17. May we contact your primary care provider to coordinate care/referrals if needed?
yes

Q18. As part of your treatment and according to state regulations, you may be asked to undergo an
urine drug screenings. The results of drug screening are confidential and not shared with anyone
outside of QuickMD. You will not be dismissed from QuickMD care solely due to a positive drug screen.
Yes

Q19. Please acknowledge that QuickMD does not participate with insurance and all costs associated
with medical services will be the direct responsibility of the patient.
I acknowledge that QMD does not participate in any insurance program.; I understand this visit is cash
pay and will not go through my insurance carrier.

Q20. In order to complete your upcoming visit, we must verify your identity. Please upload one image
that shows the front of your driver’s license.
DD2D83D2-A972-42C2-BF74-9EB657E816FD.JPG

Q21. In order to complete your upcoming visit, we must verify your identity. Please upload one image
that shows the back of your driver’s license.
DD2D83D2-A972-42C2-BF74-9EB657E816FD.JPG

Patient records page 15 of 21

Q22. In order to complete your upcoming visit, we must verify your identity. Please upload one image
that includes your face and ID.
DD2D83D2-A972-42C2-BF74-9EB657E816FD.JPG

Suboxone/MOUD

Completed on: May 04 2024

Visit type: Suboxone / MOUD

Questions
Q1. In detail, what is the reason for your visit?
refill

Q2. When did you first become dependent on opioids?

i took ulttram per prescription before they became narcotic when they became narcotic i had a nurse
practitioner suggest suboxone and ive been on these since

Q3. When was the last time you took any opioids other than buprenorphine/Suboxone (street opioids
or prescribed)?
about 16 yrs ago on reg basis

Q4. Have you been prescribed buprenorphine/Suboxone in the past? If so when was the last dose?
subutex for 14 yrs

Q5. If you have been on buprenorphine/Suboxone in the past, which dose worked well for you?
3 daily 8mg

Q6. Are you taking any other drugs, including alcohol and marijuana, besides opioids? If so, which
ones?
no absolulately not; none marijuana swells my throat shut and i cant drink at all

Q7. Are you currently receiving counseling or attending any groups for addiction care?
Yes

Q8. Would you be interested in QuickMD Counseling Services?

No

Q9. What kind of support systems do you have at home?

husband kids extended family

Q10. What other medical problems do you have?

levorotoscoliosis, degenerative disc disease, spinal fusion surgery, ulcerative colitis, reynard syn-
drome, ü restless, leg syndrome

Patient records page 16 of 21

Q11. Which medications are you taking (prescribed or non-prescribed)?
vit d3 50,000 unit cap once week, vitamin b complex injection every weeks, lincess 300mg bid, subutex
8mg tid

Q12. Do you have any allergies to medications? If yes, which ones?

naloxone morphine benadryl

Q13. What is your preferred pharmacy? Please enter pharmacy name and either phone number or
address.
family health pharmacy in sulligent Alabama 2056989770

Q14. How did you find about QuickMD?

Referred by a friend

Q15. Do you have a Primary Care Provider? If so, what is their name?
charles david rubley

Q16. If you have a primary care provider, what is their address and/or phone number?
2056987111

Q17. May we contact your primary care provider to coordinate care/referrals if needed?
yes

Q18. As part of your treatment and according to state regulations, you may be asked to undergo an
urine drug screenings. The results of drug screening are confidential and not shared with anyone
outside of QuickMD. You will not be dismissed from QuickMD care solely due to a positive drug screen.
Yes

Q19. Please acknowledge that QuickMD does not participate with insurance and all costs associated
with medical services will be the direct responsibility of the patient.
yes

Q20. In order to complete your upcoming visit, we must verify your identity. Please upload one image
that shows the front of your driver’s license.
DD2D83D2-A972-42C2-BF74-9EB657E816FD.JPG

Q21. In order to complete your upcoming visit, we must verify your identity. Please upload one image
that shows the back of your driver’s license.
DD2D83D2-A972-42C2-BF74-9EB657E816FD.JPG

Q22. In order to complete your upcoming visit, we must verify your identity. Please upload one image
that includes your face and ID.
DD2D83D2-A972-42C2-BF74-9EB657E816FD.JPG

Patient records page 17 of 21

Suboxone/MOUD

Completed on: Mar 02 2024

Visit type: Suboxone / MOUD

Questions
Q1. In detail, what is the reason for your visit?
refill

Q2. When did you first become dependent on opioids?

i took ulttram per prescription before they became narcotic when they became narcotic i had a nurse
practitioner suggest suboxone and ive been on these since

Q3. When was the last time you took any opioids other than buprenorphine/Suboxone (street opioids
or prescribed)?
about 16 yrs ago on reg basis

Q4. Have you been prescribed buprenorphine/Suboxone in the past? If so when was the last dose?
subutex for 14 yrs

Q5. If you have been on buprenorphine/Suboxone in the past, which dose worked well for you?
3 daily 8mg

Q6. Are you taking any other drugs, including alcohol and marijuana, besides opioids? If so, which
ones?
no absolulately not; none marijuana swells my throat shut and i cant drink at all

Q7. Are you currently receiving counseling or attending any groups for addiction care?
Yes

Q8. Would you be interested in QuickMD Counseling Services?

No

Q9. What kind of support systems do you have at home?

husband kids extended family

Q10. What other medical problems do you have?

levorotoscoliosis, degenerative disc disease, spinal fusion surgery, ulcerative colitis, reynard syn-
drome, ü restless, leg syndrome

Q11. Which medications are you taking (prescribed or non-prescribed)?

vit d3 50,000 unit cap once week, vitamin b complex injection every weeks, lincess 300mg bid, subutex
8mg tid

Patient records page 18 of 21

Q12. Do you have any allergies to medications? If yes, which ones?
naloxone morphine benadryl

Q13. What is your preferred pharmacy? Please enter pharmacy name and either phone number or
address.
family health pharmacy in sulligent Alabama 2056989770

Q14. How did you find about QuickMD?

Referred by a friend

Q15. Do you have a Primary Care Provider? If so, what is their name?
charles david rubley

Q16. If you have a primary care provider, what is their address and/or phone number?
2056987111

Q17. May we contact your primary care provider to coordinate care/referrals if needed?
yes

Q18. As part of your treatment and according to state regulations, you may be asked to undergo an
urine drug screenings. The results of drug screening are confidential and not shared with anyone
outside of QuickMD. You will not be dismissed from QuickMD care solely due to a positive drug screen.
Yes

Q19. Please acknowledge that QuickMD does not participate with insurance and all costs associated
with medical services will be the direct responsibility of the patient.
yes

Q20. In order to complete your upcoming visit, we must verify your identity. Please upload one image
that shows the front of your driver’s license.
DD2D83D2-A972-42C2-BF74-9EB657E816FD.JPG

Q21. In order to complete your upcoming visit, we must verify your identity. Please upload one image
that shows the back of your driver’s license.
DD2D83D2-A972-42C2-BF74-9EB657E816FD.JPG

Q22. In order to complete your upcoming visit, we must verify your identity. Please upload one image
that includes your face and ID.
DD2D83D2-A972-42C2-BF74-9EB657E816FD.JPG

Suboxone/MOUD

Completed on: Jan 30 2024

Visit type: Suboxone / MOUD

Questions
Patient records page 19 of 21
Q1. In detail, what is the reason for your visit?
i need refill on my subutex ive been using same place for years but started new job with cvs pharmacy
and its hard to take off work to drive over an hour for my monthly refill. i take subutex 8mg tid. Ive not
had a dirty urine and follow my prescription as i should.

Q2. When did you first become dependent on opioids?

i started taking ultram for back pain r/t levoscoliosis when it went narcotic a np suggested i go this route
it was suppose to be great. since then ive had spinal fusion surgery as well as ulcerative colitis

Q3. When was the last time you took any opioids other than buprenorphine/Suboxone (street opioids
or prescribed)?
its been since my spinal fusion almost 3 yrs ago

Q4. Have you been prescribed buprenorphine/Suboxone in the past? If so when was the last dose?
today last dose

Q5. If you have been on buprenorphine/Suboxone in the past, which dose worked well for you?
8mg tid

Q6. Are you taking any other drugs, including alcohol and marijuana, besides opioids? If so, which
ones?
no to all

Q7. Are you currently receiving counseling or attending any groups for addiction care?
No

Q8. Would you be interested in QuickMD Counseling Services?

No

Q9. What kind of support systems do you have at home?

great family husband n kids

Q10. What other medical problems do you have?

degenerative disc, uc, spinal fusion, levoscoliosis

Q11. Which medications are you taking (prescribed or non-prescribed)?

linzess subutex tamaflu amoxicillin Zofran Mucinex

Q12. Do you have any allergies to medications? If yes, which ones?

if I take Benadryl, it causes me to have restless leg syndrome really bad and back pain

Q13. What is your preferred pharmacy? Please enter pharmacy name and either phone number or
address.
Family health pharmacy, phone number 205-698-9770 sulligent Alabama 35586

Patient records page 20 of 21

 Q14. How did you find about QuickMD?
Google

Q15. Do you have a Primary Care Provider? If so, what is their name?
Charles David Rubley certified registered nurse practitioner located in Sulligent Alabama

Q16. If you have a primary care provider, what is their address and/or phone number?
2056987111

Q17. May we contact your primary care provider to coordinate care/referrals if needed?
yes

Q18. As part of your treatment and according to state regulations, you may be asked to undergo an
urine drug screenings. The results of drug screening are confidential and not shared with anyone
outside of QuickMD. You will not be dismissed from QuickMD care solely due to a positive drug screen.
Yes

Q19. Please acknowledge that QuickMD does not participate with insurance and all costs associated
with medical services will be the direct responsibility of the patient.
yes

Q20. In order to complete your upcoming visit, we must verify your identity. Please upload one image
that shows the front of your driver’s license.
IMG_0629.jpg

Q21. In order to complete your upcoming visit, we must verify your identity. Please upload one image
that shows the back of your driver’s license.
IMG_0630.jpg

Q22. In order to complete your upcoming visit, we must verify your identity. Please upload one image
that includes your face and ID.
IMG_1566.jpg

Disclaimer: If you have questions about a medical condition or instructions, always ask your healthcare professional.
Patient records page 21 of 21