Controlled Substance Agreement

I understand that I am required to follow up with my PCP at least every 12 months or more based on provider discretion in order for my prescription to remain active and to continue getting refills.

I agree to call for refills at least 72 hours prior to when I am due; repeated phone requests are discouraged.

I understand that ONLY the person who has signed this agreement may call for refills, except in the case of a minor.

I understand that refills will not be sent early except in rare, extenuating circumstances and at the discretion of the prescriber.

I agree that refills of my prescriptions will be made only at the time of an office visit or during regular business hours when my provider is available.

I understand that the provider managing my medication(s) listed below is.

Marcie Lavigne, MD

Her schedule is Monday: 8:30am-2pm, Tuesday: 8:30am-5pm, Wednesday: 12pm-8pm, Thursday: Off, Friday: 8:30am-5pm

I understand that refills will NOT be made by on call providers after hours or on weekends; requests made after noon on Fridays will be addressed the following week.

I agree to use one consistent pharmacy and understand that my provider will be verifying that I am receiving controlled substances from only one prescriber by checking the Prescription Drug Monitoring Program.

I understand that using a mail order pharmacy may help prevent delays in refills, especially during medication shortages.

I understand that there is a risk of psychological and physical dependence with the use of controlled substances.

I understand that illegal use or distribution of controlled substances will be reported to the proper authorities and will likely result in termination from Coal Creek Family Medicine.

I will not use illegal substances or “street drugs” nor will I misuse or self-medicate with legal controlled substances.

I will not attempt to obtain any controlled substances, including opioid pain medications, controlled stimulants, or anti-anxiety medications from any other provider.

I will safeguard my medication/s from loss, theft, or unintentional use by others. I understand that lost or stolen prescriptions will not be replaced.

I authorize my provider to provide a copy of this agreement to any pharmacy, provider, or emergency department that may need this to aid in any treatment planning.

I agree to random urine drug screening up to twice per year on the day my provider requests to determine my compliance to the medical treatment program.

I agree that I will use my medication at a rate no greater than that of the prescribed rate, and the use of my medication at a greater rate will result in my being without medication until my next refill.

I agree to sign an updated contract each year, or if my medication dose changes.

I understand that if I break this agreement, my provider will stop prescribing these medications.

Examples of breaking this agreement include but are not limited to: 

• If I trade, share, sell or misuse the medication.
• If I do not complete the urine drug screening when requested.
• If my testing shows the presence of medications that I have not made the staff aware of, the presence of illegal drugs, or does not show medications I am being prescribed.
• If my provider feels it is in my best interest that treatment be stopped.
• Any aggressive behavior towards my provider or staff.
• I consistently miss scheduled follow up appointments.

In this case, my provider may taper the medication over a period of several days as necessary to avoid withdrawal symptoms. Also, a drug dependence treatment program may be recommended.

I would also be amenable to seek psychiatric treatment and/or psychotherapy if my provider deems necessary.

I understand that this agreement is essential to the trust and confidence necessary in a provider/patient relationship.

I have been offered a copy of this agreement for my reference.

Provider Printed Name: Marcie Lavigne, MD