Andrew E. Leifer, M.D., P.C. 1202 Bergen Parkway, Suite 211,

dba Apex Treatment Services Evergreen, CO 80439

Office: 303-674-6074 Fax Line: 303-831-9601

As a participant in substance treatment, I freely and voluntarily agree to accept this treatment contract as follows:

1. I agree to keep and be on time to all my scheduled appointments.
2. I agree to adhere to the payment policy outlined by this office.
3. I agree to conduct myself in a courteous manner in the doctor's office.
4. I agree not to sell, share, or give any of my medication to another person.
5. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal. 
6. I agree not to deal, steal, or conduct any illegal or disruptive activities in the doctor's office.
7. I agree to use the same pharmacy for all prescription medications, and to provide a signed release of information form for that pharmacy. Any change in pharmacy must be immediately reported to my doctor.
8. I understand that if dealing or stealing or if any illegal or disruptive activities are observed or suspected by employees of the pharmacy where my medication is filled, that the behavior will be reported to my doctor's office and could result in my treatment being terminated without any recourse for appeal.
9. I agree that my medication/prescription can only be given to me at my regular office visits. A missed visit may result in my not being able to get my medication/prescription until the next scheduled visit.
10. I agree that the medication I receive is my responsibility and I agree to keep it in a safe. secure place. I agree that lost medication will not be replaced regardless of why it was lost.
11. I agree not to obtain medications from any doctors, pharmacies, or other sources without telling my treating physician.
12. I agree to take my medication as my doctor has instructed and not to alter the way I take my medication without first consulting my doctor.
13. I understand that medication alone is not sufficient treatment for my condition, and I agree to participate in counseling as discussed and agreed upon with my doctor and specified in my treatment plan.
14. I agree to abstain from alcohol, opioids, marijuana, cocaine, and other addictive substances (excepting nicotine).
15. I agree to provide random urine samples and have my doctor test my blood alcohol level.
16. 15. I understand that violations of the above may be grounds for termination of treatment.

Physician Signature Copyright © March 1. 2011 Andrew E. Leifer, M.D., P.C. All Rights Reserved