Rivkin Addiction Medicine · Allen Park, MI
Most patients complete their forms electronically through Elation Patient Passport — the fastest and preferred method. If you have not received a portal invitation or need a paper copy, you can download forms here.
Preferred: Complete forms through Elation Patient Passport
If you received a portal invitation from us, please use that link to complete your forms electronically. Patient Passport forms are secure, legally e-signed, and go directly into your chart — no printing, scanning, or faxing required. Check your email (including spam) for an invitation from Elation Health. Forms are sent automatically through Patient Passport prior to your initial appointment — you do not need to download anything from this page unless you have not received them.
Click any form below to download the PDF. You can fill it out digitally or print and sign by hand.
Fill out all required fields and sign where indicated. Make sure your name, date of birth, and date are included.
Upload completed forms through your Elation patient portal, or fax to (313) 334-3060. Do not email forms — email is not HIPAA-compliant.
Complete and return all four forms before your first appointment via your Elation patient portal or by fax to (313) 334-3060.
Consent to evaluation, treatment, telehealth services, and use of your health information. Includes 42 CFR Part 2 substance use disorder record protections.
Detailed information about your treatment, medications (buprenorphine, naltrexone, Vivitrol, naloxone), risks, benefits, and telehealth policies.
Agreement covering expectations for patients receiving controlled substance prescriptions, including urine drug screening, MAPS, prescription rules, and safe storage.
Authorizes billing to your insurance, assignment of benefits to the practice, and outlines your financial responsibilities including Medicare and self-pay provisions.
Additional forms available as needed. Contact the office if you have questions about which forms apply to you.
Authorizes Rivkin Addiction Medicine to release your health records to a specified provider, facility, or representative. Includes 42 CFR Part 2 substance use disorder protections.
Required for Medicare patients when a service may not be covered. Completed by staff at the time of service — download for reference only.
Describes how your medical information may be used and disclosed, including special protections for substance use disorder records under 42 CFR Part 2.