Controlled Substance Agreement

I understand I am taking a controlled substance for medical reasons. As a patient in this practice, I understand I have responsibilities regarding the use of these medications and agree to the following:

1. I understand controlled substance medications can possibly cause physical dependence/addiction.
2. I understand requests for early refills will only be considered by my primary care clinician/provider. Lost or stolen medications will not be acceptable reasons for early refills. A copy of a police report will be required for any lost or stolen medications or medication prescriptions.
3. I understand this practice does not provide long-term pain management care. If such care is needed, I will be referred to the appropriate specialist.
4. I understand this practice will routinely query the State prescription monitoring program.
5. I understand prescription refills can only be approved by my primary care clinician/provider.
6. I understand changes in controlled substance medications can only be made by my primary care clinician/provider.
7. I must bring all of my prescribed medications with me to every office visit and I understand my clinician/provider and/or his staff will count my medications at each visit.
8. I agree to random urine drug screening by my clinician/provider if he/she requests it. If I refuse, I understand my clinician/provider will no longer prescribe the medications.
9. I agree to participate in the assessments to determine risk of misuse, abuse, diversion and dependence by Risk Assessment by honestly answering the questions.
10. I will not change how much or how often I am taking the medicine without discussing changes with my primary care clinician/provider.
11. I will not request refills after office hours or on weekends because my clinician/provider may not be available during that time.
12. I will not obtain any other controlled substance medications for pain or anxiety from any other clinicians/providers (including emergency room physicians) or health-care practitioners (e.g., dentist) unless authorized by my primary care clinician/provider for special circumstances.
13. I will not use any illegal or recreational drugs or use prescription drugs purchased without a prescription.
14. I will not share my medicine with anyone else.
15. I will not sell my prescription medications.
16. I will keep all follow-up appointments as scheduled. If I miss an appointment, my medication will not be refilled until the appointment has been rescheduled.
17. I will request refills before I run out of medicine, allowing 3-4 days to process refills.
18. I will use the same pharmacy for all controlled substances and will supply my clinician/provider with the name, address, and phone number of the pharmacy so my clinician/provider may monitor refills.
    

19. I will provide a list of all controlled substance medications prescribed by my primary care clinician/provider to all other physicians and health-care practitioners (e.g. dentist).

20. I hereby give consent for my clinician/provider or a representative from this practice to call the following person and to discuss my medication use, compliance and overall treatment with him/her:

21. In addition to the above agreements, I accept the right of my primary care clinician/provider to terminate this agreement for any of the following reasons:

1. I seek or obtain any pain medication from a source other than my clinician/provider.
2. I give, sell or in any way distribute prescribed medications to any other person(s).
3. I, in any way, attempt to forge or alter a prescription.
4. My medical condition declines to the point at which, in the judgment of my clinician/provider, continued therapy with this medication presents a danger to my well-being or safety.
5. There is evidence I am no longer receiving reasonable therapeutic benefit from the medication, or it is determined I am no longer a good candidate to continue the medication.

It is my primary care clinician/provider's responsibility to determine how and if these medications will be prescribed. Decisions will be based on ongoing evaluation of my medical conditions. These guidelines are designed to protect me from dangers associated with controlled medications. If I violate these guidelines, my primary care clinician/provider may decide to discontinue or reduce the dose of my medication or discharge me from his/her practice.

STATE LAWS GOVERNING CHRONIC PAIN MANAGEMENT UTILIZING CONTROLLED SUBSTANCES DIFFER. IF YOU ARE UNSURE WHETHER THIS AGREEMENT IS COMPLIANT WITH THE LAW OF  YOUR STATE, CONSULT YOUR IN-HOUSE OPERATIONS COUNSEL.