TREATMENT AGREEMENT FOR STIMULANT MEDICATIONS

Phoenix Mental Health and Wellness

It is a requirement of our company to provide the most responsible and beneficial stimulant practices, to prevent misuse, inadequate dosing or overdosing of the medication. The goal of this treatment agreement is to ensure quality patient care is founded on evidence-based practice specific to the use of psychostimulants. Stimulant medications are federally controlled substances because they can be abused, lead to dependence, and/or withdrawal. Based on legislation your provider is required to check the national database for controlled substance prescribing prior to prescribing a controlled substance and regularly throughout the care process. Based on the Ryan Haight Act your prescriber is required to see you in- person prior to the start of prescribing a stimulant medication or one time following the end of the public health emergency for those that were prescribed a psychostimulant throughout the COVID epidemic. Telemedicine appointments must be completed via an audio-video platform. It is the clinic policy to prescribe no more than a 3-month supply of medication at a time. Refills must be approved by the provider for each request and require an appointment. It is therefore imperative that you keep all your appointments and do not lose your medication so that you do not run out of medication. Prescriptions for stimulants will only be released following completion of this treatment contract. With consenting to start this medication, you are agreeing to the following: 1) Member will take the stimulant as prescribed and not change the dose without approval from the prescribing provider. Early refills will not be given unless for compelling reasons and no more than once a year. If there is a recurrent pattern of early refill requests, the prescriber may stop the stimulant. 2) Member will notify the provider if he or she is being prescribed other controlled substances (i.e. opioids, benzodiazepines, sedatives, etc, including those prescribed by non-PMHW providers. It will be up to the provider whether stimulants may be prescribed concurrently with these medications or the dose may be changed due to the risk of adverse side effects. 3) Lost or destroyed medication will not be replaced. The provider may replace stolen medication if the member can present a police report of the theft, but this is based on provider discretion and can only be completed once throughout the entire provider-patient relationship. For any further losses, the stimulant may be tapered and discontinued. Lost/stolen medication reports will be reported to the Prescription Monitoring Program. 4) Member will not use illegal drugs. In the event that illegal drug use is suspected, the provider will stop prescribing the medication. 5) Member consents to periodic random urine samples for drug testing. If the urine drug screen is not obtained in the time frame requested by the provider (72 hours), the provider will stop prescribing the

6) Member gives permission to the provider to coordinate care with the primary care physician and other specialists involved in his or her care.

7) Member will not obtain stimulants from other sources. If there are multiple sources of stimulants, the provider will stop prescribing the stimulant. 8) Member agrees to safe and proper storage of medication: Keep medication out of sight/reach of children. Use a locked box, bag, or cabinet for safe storage. Do not put tablets down on counters, sinks, dresser, and/or nightstands or in any public unsecure space. It is easy for children to put small pieces and crumbs in their mouth, including medications, which could result in a life-threatening situation. Poison control should be notified after removal of the medication from the child's mouth. To prevent damage to the tablet form of the medication, keeping cotton or tissue in the bottle may be indicated. Always keep medication in a labeled prescription bottle with a child-proof cap. Patient's prescribed stimulant medication should always be stored with an official pharmacy label. Patients may request a second label from the pharmacy if they plan to carry medication on their person. Avoid carrying medication in a suitcase, pocket, wallet, bag, purse, or backpack. Avoid leaving the medication in the bathroom, car, or any public space. Call 911 if an accidental exposure occurs and/or go to the nearest emergency department.

9) Provider may choose to stop prescribing the stimulant if the member fails to follow the provider's advice, is having/at high risk for major side effects, fails to keep appointments, or if it is determined that the stimulant is no longer safe, helpful, or necessary.

PLEASE NOTE THAT THIS AGREEMENT WILL REMAIN IN EFFECT IF YOU TRANSFER TO A DIFFERENT PROVIDER IN THIS CLINIC.

I agree and understand all the above and provide my consent.