I understand that clinic policies and procedures regarding prescribed medications and controlled substances are in place to help both the patient and the Provider/clinic to maintain compliance with laws regarding controlled pharmaceuticals.

I understand that, if I break/breach this Agreement, my Provider may stop prescribing certain medications and/or discharge me from services at Haelan Psychiatry & Wellness.

I understand that, in the event I am discharged from the clinic, I can expect that my Provider will taper me off of the controlled medication as necessary and appropriate to avoid withdrawal complications. I understand that a drug-dependency treatment program may be recommended.

I will communicate fully and clearly with my Provider about the character and intensity of symptoms, the effects of the symptoms on my daily life, and how well the medication is helping to relieve my symptoms.

I will not use any illegal controlled substances or those that are not medically approved or those that are prescribed for someone else. I will not share, sell, or trade my medications. I will not attempt to obtain any controlled medications, including benzodiazepines, controlled stimulants, or anti-anxiety medications to treat the same symptoms from another Provider/Practitioner.

I will safeguard my medications from loss or theft.

I understand that lost or stolen controlled medications will NOT be replaced.

I understand that I need to be evaluated by my Provider at least every 30 days for refills of my controlled medications.

I authorize Haelan Psychiatry & Wellness and my pharmacy to cooperate/collaborate fully with any city, state, or federal law enforcement agency, including this State’s Board of Nursing and Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my medications. I authorize Haelan Psychiatry & Wellness to provide a copy of this signed Agreement to my pharmacy.

I agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations.

I agree that I will submit to a urine drug screening at the request of Haelan Psychiatry & Wellness to verify compliance with prescribed treatment(s).

I understand that, if I use my medication at a higher dose or frequency than prescribed, earlier refills will NOT be approved by my Provider.

I understand that, if I am currently being treated with opioids for pain management or start pain management with opioids after being prescribed any benzodiazepine, I must and will provide Haelan Psychiatry & Wellness with a signed statement from my pain management provider with their acknowledgement of concurrent benzodiazepine use.

I understand that, in the State of Arkansas, nurse practitioners currently are not allowed to initiate the first stimulant prescription. I understand that, once my stimulant prescription has been initiated by a physician or DO, my provider at Haelan Psychiatry & Wellness will be able to refill/adjust my dosage as needed and as appropriate.