• Controlled Substances Treatment Program Statement

  • We here at Adult Care of Austin are making a commitment to work with you in your efforts to get better. To help you in this work, we agree that:

    1. We will help you schedule regular appointments for medicine refills.
    2. We will make sure that this treatment is as safe as possible. We will check regularly to make sure you are not having bad side effects.
    3. We will keep track of your prescriptions and drug test routinely for compliance.
    4. We will help connect you with other forms of treatment to help you with your condition. We will help set treatment goals and monitor your progress in achieving those goals. We will work with any other doctors or providers you are seeing so that they can treat you safely and effectively.
    5. If you become addicted to these medications, we will help you get treatment and get off the medications that are causing you problems safely, without getting sick.
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  • RULE §170.3: Minimum Requirements for the Treatment of Chronic Pain

    Prior to prescribing opioids, benzodiazepines, barbiturates, or carisoprodol for the treatment of chronic pain, a physician must review prescription data and history related to the patient, if any, contained in the Prescription Drug Monitoring Program in accordance with Section 481.0764 of the Texas Health and Safety Code and §170.9 of this Chapter (relating to Prescription Monitoring Program Check). In addition, a physician must consider obtaining at a minimum a baseline toxicology drug screen to determine the presence of drugs in a patient, if any. If a physician determines that a baseline toxicology drug screen is not necessary, the physician must document in the medical record his or her rationale for not requiring the screen. (2) Treatment plan for chronic pain. The physician is responsible for a written treatment plan that is documented in the medical records. The medical record must include: (A) how the medication relates to the chief presenting complaint of chronic pain; (B) dosage and frequency of any drugs prescribed; (C) further testing and diagnostic evaluations to be ordered, if medically indicated; (D) other treatments that are planned or considered; (E) periodic reviews planned; and (F) objectives that will be used to determine treatment success, such as pain relief and improved physical and psychosocial function.

  • Controlled Substances Management Patient Agreement

  • I,   *   *  , understand and voluntarily agree that:

  • I will keep (and be on time for) all my scheduled appointments with the doctor and other members of the treatment team. If I am having trouble making an appointment, I will tell a member of the treatment team immediately.*
  • I will participate in all other types of treatment that I am asked to participate in.*
  • I will keep the medicine safe, secure and out of the reach of children. If the medicine is lost or stolen, I understand it will not be replaced until my next appointment and may not be replaced at all.*
  • I will take my medication as instructed and not change the way I take it without first talking to the doctor or other member of the treatment team.*
  • I will not call between appointments, or at night or on the weekends for refills. I understand that prescriptions will be filled only during working hours.*
  • I will always treat the staff at the office respectfully.*
  • I will not call repeatedly and harass the office staff. I understand that I will not be disrespectful to staff or disrupt routine care of other patients.*
  • I will not sell this medicine or share it with others. I understand that if I do, my treatment will be stopped.*
  • I will sign a release form to let the doctor speak to all other doctors or providers that I see.*
  • I will tell the doctor all other medicines that I take and let him/her know right away if I have a prescription for a new medicine.*
  • I will use only ONE pharmacy to get all on my medicines.*
  • I understand that routine laboratory drug testing is needed for compliance purposes and will be my responsibility if not covered by insurance.*
  • I will not use illegal drugs such as heroin, cocaine, marijuana, or amphetamines. I understand that if I do, my treatment may be stopped.*
  • I will keep up to date with any bills from the office and tell the doctor or member of the treatment team immediately if I lose my insurance or can't pay for treatment anymore.*
  • I understand that I may lose my right to treatment in this office if I break any part of this agreement.*

  • You have declined some of the requirements of the controlled substances treatment program. Please exit this form and speak to your doctor about alternatives.

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