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Controlled Substance Agreement

I have been informed that individuals who are prescribed certain controlled substances including, but not limited to, narcotic pain medicines, stimulants, benzodiazepines, and buprenorphine products, can misuse those substances or may allow misuse by others, and have some risk of developing an addictive disorder or suffering a relapse of a prior addiction. Therefore, I have been informed that it is necessary to observe strict rules pertaining to their use, and I agree to follow the terms and procedures described in this Agreement as consideration for, and as a condition of, the willingness of the physician whose signature appears below to consider prescribing or to continue prescribing controlled substances to treat my diagnosed conditions.

  1. I will inform my provider of any current or past substance use.
  2. I agree that I may be subject to a voluntary evaluation by psychologists and/or psychiatrists before any controlled substances will be prescribed to me. I agree that the need to be evaluated by psychologists and/or psychiatrists may be revisited every one (1) month, three (3) months, six (6) months, or one (1) year thereafter while taking the medication.
  3. I will obtain all controlled substances from the same pharmacy. Should the need arise to change pharmacies, I will inform the provider.
  4. I will inform PursueCare of any new medications or medical conditions, and of any adverse effects I experience from any of the medications that I take.
  5. I will inform my other health care providers that I am taking controlled substances, and of the existence of this Agreement. In the event of an emergency, I will provide the foregoing information to emergency department providers.
  6. I agree that my prescribing provider has permission to discuss all diagnostic and treatment details with other health care providers, pharmacists, or other professionals who provide my health care regarding my use of controlled substances for purposes of maintaining accountability.
  7. I will not allow anyone else to have, use, sell, or otherwise have access to these medications. The sharing of medications with anyone is absolutely forbidden and is against the law.
  8. I am aware that attempting to obtain a controlled substance under false pretenses is illegal.
  9. I agree not to alter my medication in any way, and I will take my medication whole, and it will not be broken, chewed, crushed, injected, or snorted. It is ok to cut/split strips to achieve the required dosing if recommended by my provider.
  10. I will take my medication as instructed and prescribed, and I will not exceed the maximum prescribed dose. Any change in dosage must be approved by a PursueCare provider.
  11. I understand that these medications should not be stopped abruptly, as withdrawal syndromes may develop.
  12. I will cooperate with unannounced urine or serum toxicology screenings as may be requested, by PursueCare. Failure to comply may result in immediate discharge from the practice.
  13. I understand that the presence of unauthorized and/or illegal substances in the screenings described in the paragraph above may prompt referral for assessment for a substance use disorder or change in current prescribed medications including but not limited to tapered dosing or discontinuation of medication if indicated.
  14. I understand that medications may not be replaced if they are lost, damaged, or stolen.
  15. I understand that a prescription may be given early if the physician or the patient will be out of town when the refill is due. These prescriptions will contain instructions to the pharmacist that the prescriptions(s) may not be filled prior to the appropriate date.
  16. If the responsible legal authorities have questions concerning my treatment, as may occur, for example, if I obtained medication at several pharmacies, all confidentiality is waived, and these authorities may be given full access to my full records of controlled substances administration.
  17. I will keep my scheduled appointments in order to receive medication renewals. If I need to cancel my appointment, I will do so a minimum of twenty-four (24) hours before it is scheduled.
  18. Refills generally will not be given over the phone, during the weekends, and on holidays.
  19. I understand that any medical treatment is initially a trial, with the goal of treatment being to improve the quality of life and ability to function and/or work. These parameters will be assessed periodically to determine the benefits of continued therapy, and continued prescription is contingent on whether my provider believes that the medication usage benefits me. I will comply with all treatments as outlined by my provider at PursueCare.
  20. I have been explained the risks and potential benefits of these therapies, including, but not limited to, psychological addiction, physical dependence, withdrawal, overdose, respiratory depression and death.
  21. I understand that failure to adhere to these policies and/or failure to comply with provider’s treatment plan may result in cessation of therapy with controlled substance prescribed by this provider or referral for further specialty assessment, as well as possible discharge from the practice.
  22. I, the undersigned patient, attest that the foregoing was discussed with me, and that I have read, fully understand, and agree to all of the above requirements and instructions. I affirm that I have the full right and power to sign and be bound by this Agreement.
Patient Name(Required)
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