15203 NE 72nd Ave, Vancouver, WA 98686

Controlled Substances Agreement and Informed Consent

This agreement outlines the conditions for receiving controlled substance prescriptions from The Villa Health PLLC. Please read carefully. By signing, you acknowledge that you understand the risks, responsibilities, and requirements of this treatment.

1. Medical Monitoring Requirements

• I agree to complete all required diagnostic testing, which may include:
  • EKG (heart monitoring)
  • Blood pressure and pulse checks
  • Laboratory tests
  • Urine drug screens (UDS)
  • Other tests as medically necessary
• I understand the Prescription Monitoring Program (PMP) will be reviewed before and during treatment.
• I agree to regular monitoring of vital signs and functional progress.
• I accept that medication changes may require additional testing.
• I understand that refusing medically necessary testing may result in discontinuation of controlled medications.

2. Collaborative Care

• I agree to allow communication between all my healthcare providers.
• I will provide accurate information about all my current and past medical providers.
• I understand that I may need evaluation by other specialists.
• I agree to sign necessary releases of information.
• I will inform all providers about my prescribed and non-prescribed medications.

3. Medication Management

• I will take medications exactly as prescribed and will not change the dose or frequency without provider approval.
• I will attend all required appointments.
• Prescriptions are limited to 30-day supplies.
• Lost, stolen, or damaged medications will not be replaced except as outlined in this agreement.
• I agree to use one pharmacy for all controlled prescriptions, unless an alternate pharmacy is approved due to supply issues.
• I will disclose any use of alcohol, cannabis, or other substances that may interact
• Controlled substances will only be prescribed when clinically appropriate and in compliance with DEA regulations, including electronic prescribing (EPCS They will not be prescribed across state lines unless the provider is licensed in that state.
• I understand prescriptions will be issued only when clinically appropriate and in compliance with federal DEA regulations, Washington and Oregon state laws, and opioid prescribing rules (WAC 246-919, OAR 847-015

4. Appointment Requirements 

• I will attend monthly appointments (in-person or telehealth)
• I will provide at least 48 hours' notice for cancellations.
• No refills are provided without an appointment.
• For telehealth visits, I must be physically located in Washington or Oregon, where my provider is licensed.
• Some visits may require in-person attendance for examinations, testing, or monitoring.

5. Safety and Monitoring

• I agree to random medication counts if requested.
• I will bring medications in their original containers when asked.
• I will complete urine drug screening or other testing when requested.
• I will safely store and properly dispose of medications.
• I will not share, sell, or divert my medications under any circumstances.

6. Early Refills and Lost Medications

• Lost or stolen medication will not be replaced. In rare cases where replacement is considered, a police report may be required at the discretion of the provider.
• More than two incidents within 12 months may result in termination of prescribing.
• Early refills require documentation and provider approval.
• No emergency refills will be provided after hours or on weekends.

7. Treatment Compliance

• I will follow my treatment plan as prescribed.
• I will be honest about my medication use and history.
• I understand this treatment is a trial of therapy, and continuation depends on safety
• I accept that treatment effectiveness will be regularly evaluated.
• I will complete all required monitoring and testing.
• Treatment goals will be reviewed periodically, focusing on functional improvement and overall quality of life, not just symptom relief.
• My provider will review risks and benefits of treatment at initiation and during follow-up visits.

8. Risks and Benefits

I understand that controlled substances carry risks. These may include, but are not limited

• Physical dependence
• Psychological addiction
• Tolerance, which may require dose adjustments
• Withdrawal symptoms if stopped suddenly
• Overdose potential
• Impaired ability to drive or operate machinery
• Dangerous interactions with other medications, alcohol, or substances
• Constipation, sedation, confusion, falls, sexual side effects, or hormonal changes
• Other medical risks, including cardiac risks where applicable
• Controlled substances may impair judgment, reaction time, and memory, which may increase the risk of accidents or injuries.

Disclaimer: This list is not all-inclusive. Other risks and side effects may occur depending on my individual health conditions, the type of medication prescribed, dosage, duration of treatment, and interactions with other substances. I understand my provider will review medication-specific risks with me and answer any questions I may have.

Opiod Safety:

• If I am prescribed opioids, I may also be offered a prescription for naloxone (an opioid reversal medication) and education about its use.

9. Grounds for Discontinuation

I understand my provider may discontinue controlled substance prescribing if I:

• Misuse or divert medications
• Provide false or misleading information
• Miss appointments or fail to follow this agreement
• Refuse required testing
• Engage in aggressive or threatening behavior
• Repeatedly request early refills or report lost medications
• Fail to demonstrate benefit or safety of continued treatment

  If medications are discontinued, my provider may recommend a taper to minimize withdrawal symptoms.

10. Authorization for Information Release

I authorize The Villa Health PLLC to:

• Communicate with my other healthcare providers 
• Access prescription monitoring programs (PMP) 
• Contact my pharmacy 
• Share information necessary for safe and effective care
• Obtain test results from other facilities

Understanding and Agreement

I have read or had read to me the above agreement. I understand and accept these conditions for controlled substance prescription treatment. I have had the opportunity to ask questions, and all questions have been answered to my satisfaction.