Compliance Contract Form

Adherence to Treatment Corrective Action Plan Form

PursueCare patients are expected to be compliant with appointments, medication, and the completion of timely drug screens as requested. They are responsible for communicating absences/appointment changes before the scheduled appointment. Patients are responsible for responding to messages/calls from PursueCare staff as soon as possible.

Patient Name:(Required)

Patient MRN:(Required)

Patient Date of Birth(Required)

Description of Non-Adherence to Treatment Plan: (select all that apply)(Required)

Appointment non-compliance

Continued opioid or other illicit substance use

Toxicology screen non-compliance

Medication non-compliance

Other

If other:(Required)

Description:(Required)

Specified Change to Treatment:(Required)

I agree that it is critical to the success of my care that I openly communicate with my care team, and understand the requirements for my treatment. I agree to adhere to my individualized treatment plan. I understand that non-compliance could lead to a change to my treatment plan, including the possibility of being offered a referral to a program with a higher level of supervision or multidisciplinary team review of my treatment plan who will determine if a need exists for a higher level of care and/or discontinuation of treatment with a referral to another medication assisted treatment program.

This Adherence to Treatment Corrective Action Plan is valid for 90 days from the date signed.

Patient Name:(Required)

Provider/Staff/Counselor Name:(Required)

Patient Signature:(Required)

Provider/Staff/Counselor Signature:(Required)

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Time Form Submitted(Required)

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