1. Personal use: I understand that my benzodiazepine prescription is intended for my personal use only. I will not share, sell, or trade my medication. Doing so is a violation of clinic policy and against the law. Such actions will result in discontinuation of my prescription and termination of treatment.
2. Provider notification: I will not seek benzodiazepines from other providers without notifying my prescriber.
3. Controlled medication disclosure: I will not obtain other controlled medication without first informing my prescriber. Under certain circumstances, if I obtain any additional narcotic from other physicians such as an emergency room physician, I will notify my prescriber immediately by calling the office at (617) 991-9151.
4. Medication disclosure: I will disclose all prescribed and over-the-counter medications to avoid harmful interactions.
5. Dosage and frequency: I will not alter the dosage or frequency of my medication without first consulting my prescriber during scheduled appointments (not via phone, at night, on weekends, or holidays). Any changes in dosing must be approved by my prescriber.
6. Proper use: Benzodiazepines should be taken strictly as prescribed and not altered in form (e.g., injected, crushed, snorted).
7. Drug and alcohol interaction: I will not combine my medication with other drugs without consulting my prescriber first, nor will I combine my benzodiazepine medication with alcohol. Use of benzodiazepines with other medications that may cause drowsiness, such as opioid pain relievers (including non-prescription codeine), or with alcohol can be serious and life-threatening. Naloxone will not reverse the effects of benzodiazepine overdose. I understand that their use will jeopardize my continued prescription.
8. Discontinuation and withdrawal: Discontinuing benzodiazepines abruptly after extended use can cause potentially life-threatening withdrawal symptoms. I will consult with my prescriber before stopping my medication to discuss a tapering plan.
9. Storage and disposal: All medications, including benzodiazepines, should be stored securely out of reach of others, especially children and pets. Unused medication should be returned to the pharmacy for safe disposal.
10. Appointment and refill policy: Patients are responsible for scheduling regular appointments and contacting the office at least 72 hours before running out of medication for refills. Refills are processed during office visits or regular office hours only.
11. Renewal conditions: Renewals of my benzodiazepine prescription are contingent upon my adherence to scheduled appointments and compliance with prescription directions. I understand that my prescriber will determine the frequency of my visits, and I will comply with these expectations. If I need to cancel an appointment, I agree to do so at least twenty-four (24) hours before the scheduled time by calling the office at (617) 991-9151.
12. No early refills: I understand that I may not obtain an early refill or replacement supplies for lost, stolen, or damaged benzodiazepine medication.
13. No pharmacy refill requests: I understand that pharmacy refill requests for controlled medications, including benzodiazepines, are not accepted.
14. Substance use disclosure: I will inform my prescriber of alcohol or drug use, past or present, as well as any history of alcoholism or addiction.
15. Toxicology screenings: I consent to random urine or serum toxicology screenings as may be requested by my prescriber. Further refills or prescriptions will be contingent upon completion of the requested screening. I understand that all out-of-pocket expenses associated with drug screenings are my responsibility.
16. Pill counts: I consent to random pill counts as may be requested by my prescriber. If requested, I will bring my medication in the original container to my next in-office appointment within the requested timeframe, so that a staff member may verify the number of pills in my possession. Further refills or prescriptions will be contingent upon completion of the requested screening.
17. Substance use screening and consequences: I understand that the presence of unauthorized and/or illegal substances, or the absence of prescribed medications, in the screenings described in this agreement may prompt referral for assessment for a substance abuse disorder or discharge from the practice. An unexpected result on the urine drug screen may lead to the discontinuation of my benzodiazepine prescription.
18. Pregnancy: If I intend to become pregnant or become pregnant during treatment, I understand that it is crucial to inform my prescriber promptly. This notification is necessary to discuss the potential risks of benzodiazepines to the fetus and to consider appropriate tapering options. I acknowledge that failure to notify my prescriber may result in harm to my unborn child. I absolve my prescriber and Aspire Medical Group from any liability for harm that may occur to myself and/or my unborn child.
19. Adjunctive management programs: I agree to participate in adjunctive management programs as recommended by my prescriber, such as psychotherapy, meditation, exercise, use of non-controlled medications, and/or other complementary therapies.
20. Information sharing: I consent to sharing my medical information with other healthcare professionals involved in my care if it is deemed medically necessary. I acknowledge that my prescriber has the authority to disclose relevant information to facilitate comprehensive and coordinated healthcare services.
21. Prescription monitoring program: I understand that my prescriber will verify that I am receiving only the controlled substances that I have reported previously and only from prescribers that have been previously reported by checking the Massachusetts Prescription Drug Monitoring Program, as required by law.
22. No exceptions requests: I understand and agree that I will not place calls to the office staff with demands for variations or exceptions to this agreement. I acknowledge that adherence to the terms outlined in this agreement is essential for safe and effective treatment. Any concerns or questions regarding my treatment plan should be discussed during scheduled appointments or as otherwise instructed by my healthcare provider.