Healthcare Sobriety Contract

HEALTHCARE SOBRIETY CONTRACT

This Sobriety Contract (the "Agreement") documents the mutual understanding between the Patient and the Healthcare Provider regarding required sobriety, monitoring, and related treatment conditions as part of ongoing care. Patient Name:

Healthcare Provider / Facility: Effective Date:

Patient Information

Insurance & Billing

Medical History

Sobriety Terms and Conditions

1. Patient Obligations: The Patient agrees to the following conditions as consideration for continued treatment and/or prescription of controlled substances:

1. Maintain continuous abstinence from alcohol, illicit substances, and non-prescribed controlled medications. Patient initials:
2. Attend all scheduled appointments, counseling, and recommended support programs. Patient initials:
3. Take medications only as prescribed by the treating provider and do not share prescribed medications. Patient initials:

2. Monitoring and Testing: The Patient consents to monitoring intended to verify sobriety, including but not limited to:

Urine drug screening as ordered by the Provider

Breath alcohol testing as ordered by the Provider

Random and surprise testing at times designated by the Provider or treatment program

The Patient authorizes the Provider and treatment team to collect specimens, document results in the medical record, and disclose results to other treating clinicians as necessary for treatment coordination and safety. Patient acknowledges specimen collection procedures, chain of custody, and that adverse results may affect treatment decisions.

Consequences of Non-Compliance

Non-compliance, including positive tests for alcohol or non-prescribed substances, missed appointments, refusal of testing, or diversion of medications, may result in one or more of the following actions at the Provider's discretion:

• Increased frequency of monitoring and testing
• Modification, suspension, or discontinuation of controlled substance prescriptions
• Referral to a higher level of care, addiction treatment program, or safety intervention
• Notification of relevant treating clinicians and, where permitted by law and clinical necessity, designated family or support persons

Consent to Release and Confidentiality

By signing this Agreement, the Patient authorizes the release of sobriety monitoring results and treatment-related information to the Provider's care team and to any behavioral health or addiction treatment entities involved in the Patient's care. This authorization is limited to information necessary to coordinate treatment and ensure patient safety. The Provider will maintain confidentiality consistent with applicable law.

I acknowledge and authorize release of testing and treatment information as described above.

Voluntary Participation & Right to Withdraw

Participation in monitoring and required activities is voluntary. The Patient may withdraw consent for disclosure or monitoring; however, the Provider retains the right to modify or terminate treatment in response to withdrawal of consent or non-participation when the Provider determines that continued treatment poses risk to safety or is incompatible with standard of care.

Acknowledgment and Certification

I certify that I have read and understand the terms of this Sobriety Contract. I have had the opportunity to ask questions and to receive answers to my satisfaction. I understand the expectations, monitoring procedures, and potential consequences for non-compliance. I agree to comply with the terms set forth herein while under the care of the Provider named above.

Patient Signature indicates consent to monitoring, treatment conditions, and release of information as necessary for care and safety.

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