Agreement For Long Term Controlled Substance Prescriptions

The purpose of this agreement is to prevent any misunderstanding regarding long-term controlled substance prescriptions that you may be prescribed by the providers at Aspire Medical Group. The goal is to treat you safely with these potent medications and to prevent abuse or diversion of these medications. This agreement is also set forth to assist you and your provider in complying with the law regarding controlled pharmaceuticals. Because these medications have the potential for abuse or diversion, strict accountability is necessary for both medical, safety, and legal reasons.

Personal Use: I understand that my controlled substance prescription is intended for personal use only. Sharing, selling, or trading my medication is prohibited and is a violation of clinic policy and federal law. Such actions will result in the discontinuation of my prescription and termination of treatment.

Storage and Disposal: Controlled substance medications must be stored securely, out of reach of children and pets. Unused or expired medication should be returned to the pharmacy for proper disposal.

Dosage and Frequency: I will not alter the dosage or frequency of my medication without first consulting my prescriber. Any changes in dosing must be approved during scheduled appointments and not via phone, after hours, or on weekends.

Proper Use: Controlled substances must be taken strictly as prescribed. Altering the form (e.g., injecting, crushing, or snorting) is prohibited.

Misuse: I understand that using medication at a greater rate than prescribed may result in being without medication for a period of time. Medication may be tapered or discontinued if misuse is suspected.

Safety Precautions: I will exercise caution when driving or operating heavy machinery while taking these medications, as they may cause drowsiness or impair mental abilities.

Drug and Alcohol Interaction: I will not combine my medication with other drugs or alcohol without consulting my prescriber. Combining controlled substances with alcohol or illicit drugs can be dangerous. I understand that use of alcohol, marijuana, or other illegal substances while taking controlled substances may jeopardize my continued treatment.

Dangerous Medication Combinations: I understand that certain combinations of prescription medications, such as benzodiazepines and opioids, are particularly dangerous. Receiving these or other controlled substances without notifying my provider may result in the termination of services.

Prescription Monitoring: I understand that my prescriber will verify that I am only receiving controlled substances that I have reported, and they will review the Massachusetts Prescription Drug Monitoring Program as required by law.

Substance Use Disclosure: I will inform my prescriber of any alcohol or drug use, both past and present, as well as any history of alcoholism or addiction.

Toxicology Screenings: I consent to random urine or serum toxicology screenings as requested by my prescriber. I understand that further prescriptions or refills are contingent upon completion of the requested screening. I am responsible for any out-of-pocket expenses associated with these screenings.

Pill Counts: I consent to random pill counts as requested by my prescriber. If requested, I will bring my medication in its original container to my next appointment for verification. Further refills will depend on completion of the requested pill count.

Substance Use Screening and Consequences: I understand that the presence of unauthorized substances, or the absence of prescribed medications in screenings, may result in a referral for substance abuse assessment or discharge from the practice. Unexpected results may also lead to discontinuation of my controlled substance prescription.

Adjunctive Management Programs: I agree to participate in adjunctive management programs as recommended by my prescriber, including psychological testing, psychotherapy, behavioral modification, school-based interventions, or job modifications.

Pregnancy: If I become pregnant or intend to become pregnant during treatment, I will inform my prescriber promptly. This is essential to discuss the risks to the fetus and consider tapering options. I absolve Aspire Medical Group and my prescriber of any liability for harm to myself or my unborn child if I fail to notify my prescriber of pregnancy

Information Sharing: I consent to the sharing of my medical information with other healthcare professionals involved in my care, if deemed medically necessary. I acknowledge that my prescriber has the authority to disclose relevant information for comprehensive care.

Confidentiality and Legal Inquiries: If legal authorities inquire about my treatment (e.g., obtaining medication from multiple pharmacies), my confidentiality may be waived, allowing them access to my records of controlled substances administration.

Legal Compliance: I understand that attempting to obtain controlled substances under false pretenses is illegal.

Confidentiality and Legal Inquiries: If legal authorities inquire about my treatment (e.g., obtaining medication from multiple pharmacies), my confidentiality may be waived, allowing them access to my records of controlled substances administration.

Controlled Medications from Other Providers

• I will not obtain controlled medications, including benzodiazepines, controlled stimulants, gabapentin, anti-anxiety medications, buprenorphine, or sleep medications (sedative hypnotics, orexin antagonists), to treat the same symptoms from any other provider without informing my prescriber.
• If I obtain additional controlled substances, such as narcotic medication from an emergency room or another provider, I will notify my prescriber within 24 hours by calling the office at (617) 991-9151.

Medical History and Medication Disclosure

• I will inform my provider of any new medications, medical conditions, or emergency treatment. I will disclose all other medications I am taking, including over-the-counter, herbal, and prescribed medicines, to avoid dangerous drug interactions. I will also inform my other healthcare providers that I am taking controlled substances and provide this information in the event of an emergency.
• I will inform my provider of any new medications, medical conditions, or emergency treatment.
• I will disclose all other medications I am taking, including over-the-counter, herbal, and prescribed medicines, to avoid dangerous drug interactions.
• I will inform my other healthcare providers that I am taking controlled substances and provide this information in the event of an emergency.

 

Refill Policy

• Timely refill requests are the patient's responsibility, and 3 business days are required for processing all refill requests. I am responsible for scheduling regular appointments and contacting the office at least 72 hours before running out of medication for refills.
• Refills will only be processed during office visits or regular office hours. Renewals of my controlled substance prescription are contingent upon my adherence to scheduled appointments and compliance with treatment.
• I understand that a prescription may be given early if the prescriber or I will be out of town when the refill is due, but such prescriptions will include instructions to the pharmacist regarding the appropriate refill date.
  Appointment Cancellations:

No Early Refills

• Controlled substances will not be refilled earlier than the prescribed interval. Lost, stolen, or damaged controlled substance prescriptions will not be refilled early. No exceptions.

No Pharmacy Refill Requests 

• I understand that pharmacy refill requests for controlled medications will not be accepted.

Appointment Cancellations

• If I need to cancel an appointment, I agree to do so at least 24 hours in advance by calling (617) 991-9151 or a cancellation fee will be assessed. Missed appointments without proper notice may result in a delay in processing my prescription(s). 

 

• I will only use one pharmacy to obtain my medicine. If I decide to change pharmacies, I will notify my provider.
• My provider may communicate with the pharmacist about my medicines.

• I certify that I have read this form in its entirety and fully understand its contents. I have been given the opportunity to ask questions, and all of my questions have been answered to my satisfaction.
• I consent to the use of stimulants as part of my treatment plan and understand that this treatment will be governed by the terms outlined in this agreement.
• I have informed my healthcare provider of all my medical conditions, known allergies, past adverse reactions, and all medications and supplements I am currently taking.
• I understand that failure to comply with this agreement may result in the discontinuation of my controlled substance prescriptions and/or termination from the practice. I acknowledge that my prescriber reserves the right to adjust or discontinue treatment as necessary.
• I acknowledge that no guarantees have been made regarding the outcome of this treatment.
• By signing this form, I voluntarily consent to treatment, agree to the use of electronic records and signatures, and confirm that I have the legal authority to be bound by this agreement. I voluntarily accept the risks, conditions, and terms outlined in this document.
   

By providing my electronic signature below, I agree to the terms and conditions outlined in this agreement. I agree to the use of electronic records and signatures. I acknowledge that I have read the related consumer disclosure.

The parties acknowledge and agree that this financial agreement form may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall include faxed versions of an original signature or electronically scanned and transmitted versions (e.g., via PDF) of an original signature.