Marsh Island Psychiatry PLLC Controlled Substance Agreement The purpose of this agreement is to set out the rules that this office follows in order to prescribe medications that are controlled by the Drug Enforcement Agency (DEA). We are committed to making sure we address your needs while providing you with alternatives designed to minimize the addictive potential of the controlled substance. To clarify my expectations in giving you this medication and to emphasize the risk of taking these substances I am requesting that you read and sign this agreement.

I understand that I am being prescribed a controlled substance; therefore, I must adhere to the following restrictions. Failure to conform to any of the below listed restrictions may result in being dismissed as a patient.

1. I will not use alcohol/illegal drugs while being prescribed medication(s).

2. I will not take any other prescribed controlled medications without first notifying my provider.

3. I will notify my provider immediately of any other provider(s) currently prescribing me a controlled substance(s) or that have been prescribed to me in the past thirty days including emergency rooms and urgent care centers. Legally, failure to do so is a crime (obtaining or attempting to obtain drugs by fraud and/or deceit).

4. I will submit to random urine and/or serum drug screens as ordered.

5. I will only fill prescriptions for controlled substance at the pharmacy listed below. | will inform my provider of any plans to change pharmacy. I will not obtain controlled substances from more than one pharmacy at a time. The only exception will be for acute need outside of the local area. | will authorize my provider to communicate with my pharmacist.

6. I authorize my provider to communicate with all providers I have seen when necessary.

7. I understand it is illegal to share this medication.

8. I agree to keep my medication safe and secure in order to prevent loss or theft.

9. I understand that I will be taken off this medication if there is evidence of addiction and/or misuse.

10. I understand that some controlled substances may cause drowsiness and slower reflexes, interfering with the ability to drive and operate machinery and causing short-term memory impairment. I understand that overdose of this medication may cause death.

11. I agree to keep all scheduled appointments with my provider. My medication may be weaned and discontinued if I fail to attend my scheduled appointments.

12. I also understand that part of my treatment may involve reduction and discontinuation of any addictive medications. I understand and accept the risk of physical dependence and/or addiction that can occur with this medication. I understand that dose reduction may cause temporary discomfort, which my provider will work to mitigate to the best of their ability. I agree to work with my provider to discontinue these medications when necessary.

13. I understand I may be called at any time to the office for a count of all my remaining medications. I agree to arrive on the day notified and will be responsible for any costs this may incur.

14. No refills will be authorized on weekends, holidays or after office hours. If failure to secure your medications results in losing your medications, a refill will NOT be provided. A one-time exception may be made in the event of a burglary if an official police report is provided.

Iread the above, asked questions and understand this agreement. If I violate this agreement, I know that my provider may discontinue my treatment.