Click an appendix title below to view the material:


Appendix 1: Consent for Release of Confidential Information
Appendix 2: Treatment Information Sheet
Appendix 3A: Ten Factor Office-Based Criteria Check List
Appendix 3B: Guidelines for Assessing Appropriateness for Office-Based Therapy
Appendix 4: Buprenorphine Treatment Agreement/Contract
Appendix 5: Treatment of Opioid Dependence During Pregnancy Demographic Sheet
Appendix 6: Opioid-Agonist Therapy During Pregnancy Medication Provider Checklist
Appendix 7: Clinical Institute Narcotic Assessment (CINA) Scale for Withdrawal Symptoms
Appendix 8: Clinical Opiate Withdrawal Scale (COWS)
Appendix 9: Medication Provider Visit Flow Sheet
Appendix 10: Community-Based Nursing/Social Services Checklist
Appendix 11: Communication Tool Fax Form
Appendix 12: Medicaid Family Planning “BE SMART” Program