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Patient / Physician Matching System : Patient Application

The National Alliance of Advocates for Buprenorphine Treatment (NAABT)

If you have been unable to find appropriate buprenorphine treatment,
you may register on the patient/physician matching system.

Here's how it works:

1) Place yourself on the list, anonymously and confidentially.

2) Certified treatment providers will review applicants.

3) When a treatment provider has an opening and/or matches the criteria they will email you, and ask you to contact them to further discuss your treatment.

To learn more about the Patient Physician Matching System click here.

NAABT Home Page

At no time will naabt.org ask for your name or publish your email address, you will be assigned a NAABT ID number and that is what the doctor will see. The only time you will need to identify yourself is when you arrange for an appointment with a doctor, confidentially on the telephone. If you wish further anonymity, you may sign up for a 3rd party email address, at hotmail or yahoo. Counselors may sign up on behalf of a patient who may not have access to a computer.
 
Patient Application Form
Zip Code:
Sex: Male    Female
How long have you been addicted to opioids?: years
Year of birth:
(must be at least 18)
What kind of opioids are you currently taking?:
(check all that apply)		 Oxycodone  Hydrocodone   
Methadone  Heroin
Buprenorphine  Morphine        
Other opioid pain killers
What other drugs or medications are you taking?:
(Illegal, prescription, over-the-counter, birth control, herbal, etc.)
What types of treatment have you tried?:
(check all that apply)		 Cold Turkey  Rapid Detox
Rehab Facility  Methadone
Buprenorphine Other
How many times have you tried to quit?:
How far are you willing to travel for treatment?:
(You may be required to go as often as 3-4 times per week at first) 		miles
Is there a history of addiction in your family?: Yes    No
Are you employed? Yes    No
Do you have insurance or other means to pay for treatment?: Yes    No
Do you currently see a counselor or psychologist for your addiction?: Yes    No
Are you eligible for Veteran Administration health care benefits?: Yes    No
How did you discover this service?:
Statement to doctor (400 characters max.):

Here include the name of your insurance company, if any, alternate payment plan information, a physician referral, whether you are interested in maintenance or induction, or any relevant information you feel the doctor may want to know. [?]

 (400 Character Limit)

Characters Left
E-mail Address (where a doctor may contact you):
(Counselors and advocates acting on behalf of their clients may use the same e-mail address for several clients.)
Choose a password:
Confirm password:
I agree to the terms of use and privacy policy.