Medication First Site Listing

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Please complete this form for each site that offers buprenorphine and/or methadone treatment to walk-in clients or within 5 business days of a client phone call. This listing will appear on a Medication First map of providers, with map updates posting every 1 to 3 days. You will be provided a link for each listing which will allow you to always go back and edit the listing. You can also request changes by emailing npresnall@planyourrecovery.com

Person completing form *

Email *

Phone *

Name of Treatment Site *

Address number and street name with standard street type abbreviation (e.g. 12 Main St.) *

City *

State *

Zip *

Intake Phone Number *

Which maintenance pharmacotherapies do you offer? *

methadone

buprenorphine

XR naltrexone

Required

How quickly can you generally get clients in to see a buprenorphine or methadone prescriber? *

Walk-in

Same day (with phone call)

1 business day

2-3 business days

4-5 business days

What is the minimum counseling requirement (individual or group) for a patient to start receiving buprenorphine or methadone treatment? *

none

one counseling visit per month

one counseling visit per week

intensive outpatient program

Other:

Payment *

Medicaid

Medicare

Commercial Insurance

State funding for uninsured

Other:

Required

Other info for patients (optional)

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