Emergency Contact Information (Other Than Responsibly Party)
I authorize disclosure of records/information about me between:
Michigan Psychiatric & Primary Care Clinic, PC6110 Abbot RoadEast Lansing, MI 48823ph: 517.332.5342 | fax: 517.332.3325
You have been given information about your medical condition and the recommended medical, surgical, and/or diagnostic procedure(s), and medication therapies to be used. The risks and benefits have been clearly communicated, as well as alternative methods, if applicable. This consent form is designed to provide a written confirmation of such discussions by recording some of the more significant medical information given to you. It is intended to make you better informed so that you may give or withhold your consent to the proposed procedure(s) and/or treatment recommendations.
2. Proposed Procedure(s): I understand that the procedure(s) proposed for evaluating and treating my condition is/are:
3. Risk/Benefits of Proposed Treatment, Procedure(s) and/or Medications:
A. Just as there may be benefits to the treatment, procedure(s) and/or medications proposed, I also understand that medical treatments, surgical procedures and medication therapies involve risks. These risks include allergic reaction, bleeding, blood clots, infections, adverse side effects of drugs, and even loss of bodily function or life.
B. I also realize that there are particular risks associated with the treatment, procedure(s) and/or medication therapies proposed for me and that these risks include, but are not limited to, those enumerated by my physician.
4. Complication; Unforeseen Conditions; Results: I am aware that in the practice of medicine, other unexpected risks and complications not discussed may occur. I also understand that during the course of the proposed treatment, procedure(s) and/or medication therapies, unforeseen conditions may be revealed requiring the performance of additional treatment, procedures, and/or medication therapies, and I authorize such treatment, procedures, and/or medication therapies to be performed. I further acknowledge that no guarantees or promises have been made to me concerning the results of any procedure or treatment or medication regimen.
5. Consent to Treatment and Procedure(s): I request and authorize outpatient care as my physician, his/her assistant or designee (collectively called the physicians) may deem necessary or advisable. These include but are not limited to routine diagnostic radiology and laboratory procedures, routine drugs, biologicals and other therapeutic applications, and routine medical, nursing and facility care. I understand that in emergency situations it maybe be necessary or advisable for the physician to perform other additional or extended services beyond those contemplated at time of admission to preserve my (the patient's) life or health. I consent to these treatment services, procedures and medication therapies. I understand that facility care is directed by me (the patient), physician and the facility personnel rendering care and services to me (the patient) according to the physician's instructions and that some of the physicians who manage the care are independent physicians and not agents, representatives or employees of the facility.
BY SIGNING THIS, I AGREE I HAVE RECEIVED THIS PRACTICE'S NOTICE OF PRIVACY PRACTICES written in plain language. The Notice provides in detail the uses and disclosures of protected health information that may be made by this practice, individual rights and the practices' legal duties with respect to protect health information. The Notice includes:
This practice reserves the right to change the terms of its Notice of Privacy Practices and to make new provisions effective for all protected health information that it maintains. I understand that I can obtain this practice's current Notice of Privacy Practices on request.
BY SIGNING THIS POLICY YOU AGREE YOU UNDERSTAND AND AGREE TO BE BOUND BY THE FOLLOWING TERMS:
I have read and understand the practice's financial policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time without direct notice to me and agree to be bound by any amendments.
What should I know about these medications?
This controlled medication may help me.
Anxiety and Sleep Medications can cause:
These medicines require a face to face appointment every 3 months.
Combining these medicines with other drugs (like psychotropic sedating medications or other controlled substances like opiates or alcohol) can cause:
Stimulant medications (for ADD/ADHD) can cause:
These medicines require a face to face visit with the provider every 3 months.
If I must stop this medication for any reason, I may need to stop it slowly. Stopping it slowly will help me avoid feeling sick from withdrawal (flu-like) symptoms. If I decide to stop my medication I will contact my provider.
If l, or anyone in my family has ever had a drug, substance or alcohol problems, I have a higher chance of getting addicted to this medication. If I do not use this medication exactly as prescribed, I risk hurting myself and others. I will not increase my medicine dose without being told to do so by my provider.
I will inform my provider right away if another provider, like ER provider, specialist, dentist etc., prescribes a controlled substance. This medicine will not be refilled early. I am in charge of my medicine.
What can I do to help?When asked, I will give a urine and/or blood sample to help monitor my treatment. I will to go to appointments and tests set up by my provider. These may include psychotherapy, physical or occupational therapy, x-rays, labs, etc. If I miss my appointments it may not be safe for me to stay on the medicine and my provider may require an office visit before giving refills.
If my provider decides the risks outweigh the benefits of this medication, it will be stopped in a safe tapering manner.
How can I get my prescriptions?I can only get this prescription from my provider with an appointment. Refills will be determined on an individual basis. Medications will only be given in 1 month supplies. I will need periodic office visits if continued usage is needed.
What are the reasons for ending this agreement?I may not be able to obtain controlled prescriptions if I do not follow this agreement. I know that by State of Michigan law, diverting these controlled substances for non-medical use (lying to get medications, giving, trading or selling these medications) is a crime that we will report.