CONTROLLED SUBSTANCE FORM

The purpose of this contract is to protect your access to controlled substances and to protect our ability to prescribe to you.

The long-term use of such substances as opioids (Narcotic pain medicines) benzodiazepine (Xanax, Klonopin), and stimulants (Adderall, Ritalin etc barbiturate sedatives (Ambien, Halcion) is controversial because it is not certain whether they help patients over the long term. Patients who are prescribed these drugs have some risk of developing an addictive disorder developing or suffering a relapse of a prior addiction. The extent of this risk is not certain.

Because these drugs can be abused by the patients who receive them, or by others, it is necessary to observe strict rules when they are prescribed over the long term. For this reason, we require each patient receiving long term treatment with these medications to read and agree to the following policies.

It is agreed by you, the patient, as consideration for, and a condition of, the willingness of the physician/nurse practitioner whose signature appears below to consider prescribing or to continue prescribing 'controlled substances to treat your condition.

1. All psychiatric controlled substances must come from a physician/nurse practitioner in this office. My controlled substances will come from the physician/nurse practitioner whose signature appears below, or during his or her absence, by the covering prescriber.
2. I will inform my physician of any current or past substance abuse, or any current or past substance abuse of any immediate member of my immediate family.
3. I will inform the office of any new medications or medical conditions, and of any adverse effects I experience from any of the medications that I take.
4. I agree that my prescribing physician/Nurse practitioner has permission to discuss all diagnostic and treatment details with dispensing pharmacists or other professionals who provide my health care for purposes of maintaining accountability.
5. I will not allow anyone else to have, use, sell, or otherwise have access to these medications.
6. I will take my medication as prescribed and I will not increase the dose without permission from the prescribing physician/ Nurse Practitioner.
7. I understand that these drugs should not be stopped abruptly, as withdrawal syndromes will likely develop.
8. I will cooperate with random drug counts, and unannounced urine or serum toxicology screens that may be requested.
9. I understand that the presence of unauthorized substances may prompt referral for assessment for a substance abuse disorder and may result in medications not being prescribed and/or discharge from the practice.
10. I understand that these drugs may be hazardous or lethal to a person who is not tolerant of their effects, especially a child and that I must keep them out of reach of such people for their own safety.
11. I understand that medications may not be replaced if they are lost, damaged, or stolen. If any of these situations arise that cause me to request an early refill of my medication, I will be required to complete a statement explaining the circumstances. At that time a determination will be made as to whether I may receive an early refill. A signed police report is required for stolen medications and does not guarantee that medications will be filled early.
12. I will keep my scheduled appointments in order to receive medication renewals. No refills will be given by phone, fax, at night, or on weekends.
13. I understand that any medical treatment is initially a trial and that continued prescription is contingent on whether my physician/nurse practitioner believes that the medication usage benefits me.
14. I have been explained the risks and potential benefits of these therapies, including, but not limited to psychological addiction, physical dependence, withdrawal and over dosage that could result in adverse events including death.
15. I affirm that I have full right and power to sign and be bound by this agreement, and that I have read, understand, and accept all of its terms.

I understand that if I do hot follow/cooperate with the guidelines and instructions in this agreement that I can be discharged at any time without notice.