Prescription Medication Agreement For Controlled Substance Treatment of Pain.
Nevada law requires a patient to enter into a “Prescription Medication Agreement” if a controlled substance is to be continued for more than 30 days for treatment of pain. I understand that This agreement will be updated every 365 days, or if there is a change to my treatment plan. I understand the treatment of pain with controlled substance comes with its risks and responsibilities on my part of which my practitioner has made me aware. The purpose of this agreement is to help both me and my practitioner comply with the law. (Please initial within each number. (Please initial and sign below to indicate your understanding of all parts of this document.)
Regarding my treatment plan and the goals of the treatment of my pain, including the appropriate us of controlled substance.
Thank you for choosing Partida Corona Medical Center as your healthcare provider. Please carefully read and initial by each statement and sign below. This policy has been put in place to ensure that financial payments are recovered to allow us to continue to provide quality medical care for our patients. It is important that we work together to assure that payment for services is as simple and straightforward as possible. Our practice manager or billing department will be glad to discuss these policies with you.
I authorize Partida Corona Medical Center to use and disclose the protected health information described below to: (whom you would like us to share your information with)
Effective Period:Option 1This authorization for release of information covers the period of healthcare from the the following dates. MM-DD-YYYY - TOblanks OROption 2All Past,Present,and Future periods. Please type in the text to confirm all past present and future periods.