High Risk Drug Agreement (Controlled Substance Contract)

1

I am aware of my condition and I am receiving medications for the condition. I understand my Provider is not required to prescribe high risk drugs for me and can stop them at any time. I will follow all rules and procedures listed in this agreement. Select YES if you agree to the above statement.

YESNO

2

Tamia Musgrave is the only Five Star Integrated Health Service Provider who will prescribe High Risk Drugs for me. I will not seek other medications from another Provider. If an additional High-Risk Drug/Scheduled DEA controlled drugs is needed to be prescribed by another Provider, I agree to notify Provider Musgrave as soon as possible, prior to starting the additional High-Risk Drugs/Scheduled DEA controlled drug.Select YES if you agree to the above statement.

YESNO

3

Refills will NEVER be provided by phone without a visit. I cannot get a refill before my next scheduled appointment. If I do not keep my appointment or if I cancel two (2) appointments with less than two (2) working days’ notice or do not show up for two (2) appointments, I will not get a refill and my Provider may end this agreement and stop prescribing my medicines.Select YES if you agree to the above statement.

YESNO

4

I will not take medications in larger amounts or more frequently than is prescribe. I will only take as prescribed. I understand if I take more medicine than prescribed my Provider may end this agreement. I understand that if my prescription runs out early for any reason, I will have to wait until the next prescription is due.Select YES if you agree to the above statement.

YESNO

5

I will not take ANY other medicines (for example sleeping pills, sedatives, drugs, or ANY pain medicines) without getting my Providers approval first.Select YES if you agree to the above statement.

YESNO

6

I will not seek, accept, or use any controlled substance except the High-Risk Drug my Provider prescribes for me. “Controlled Substance” is (1) ANY medicine prescribed by another Provider at 5StarIHS or anywhere else. (2) ANY illegal or street drug (such as marijuana (if you do not have a MMCC card, Providers name and registration number required) “bath salts”, cocaine, opioids, or methamphetamine. Select YES if you agree to the above statement.

YESNO

7

5StarIHS Provider’s will NOT refill ANY lost or stolen medicine. I will protect and keep my High-Risk Drug safe in a lockbox. I will keep all my High-Risk Drugs out the reach of children. I will not give or sell my medication to ANYONE. Select YES if you agree to the above statement.

YESNO

8

If requested by my Provider within 48 hours, I will complete periodic urine drug screening to assist in verifying compliance with my treatment plan. If I refuse, my Provider may stop my medicine. I understand my medication will not be sent to the pharmacy until my Provider has received my results.Select YES if you agree to the above statement.

YESNO

9

I know my Provider and other 5StarIHS Providers may end this agreement and my High-Risk Drugs if: (1) I try to get or do get High Risk Drugs from anybody except my 5StarIHS Provider. (2) I give, sell, or in any way distribute my High Risk Drugs to anybody else. (3) My medical condition changes in such a way that my Provider determines that continuing me on High Risk Drug put my well being or safety at risk. (4) My Provider determines that I am no longer (A) Benefiting medically for the High Risk Drug or (B) A good candidate to continue the High Risk Drug .Select YES if you agree to the above statement.

YESNO

10

I understand if I do not follow one or more of the rules, my 5StarIHS Provider may end this agreement and stop prescribing my High-Risk Drug or may decide that I can no longer see my Provider or any other 5StarIHS Provider.Select YES if you agree to the above statement.

YESNO

11

I will fill my prescriptions at the pharmacy provided. If I change pharmacies, I will contact my Provider’s office with the name, address, and phone number of my new pharmacy. My Provider may send a copy of this agreement to the pharmacy I have named and any new pharmacy I decide to use.

12

Pharmacy Name

13

Pharmacy Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

14

Pharmacy Phone

Area Code

Phone Number

15

Patient Full Name

First Name

Last Name

16

Patient Date of Birth

Date

17

Patient Signature (if under 18 years old, parent or guardian must sign)

Clear