Southpointe Psychiatry & Wellness
CONTROLLED SUBSTANCE AGREEMENT
I, (name) ________________________________________________ (DOB) _________________, understand that my provider is prescribing a controlled substance medication as part of my treatment plan.
Controlled substances (for example stimulants, benzodiazepines, hypnotics, opioids, hallucinogens, anabolic steroids) are highly regulated by the government because of the potential for abuse or addiction. The control applies to the way the substance is made, used, handled, stored, and distributed. This controlled substance policy is a tool for communication allowing us to work together in good faith. This requires cooperation, trust and mutual respect. If you cannot agree to the following terms, we will be unable to prescribe controlled medication.
Initial: ______ I will take the medication exactly as prescribed, and I will not change the medication dosage and/or frequency without the approval of my provider. I understand selling, trading, or giving medication to another person, including a family member is ILLEGAL.
Initial: ______ I understand it is my responsibility to schedule and keep all appointments. I understand that if I have not been seen in 60-90 days, no medication can be refilled unless seen for an office visit or arranged with your provider.
Initial: ______ I understand that no early refills of medication will be authorized. If the medication is lost, misplaced, stolen or refill is needed sooner than prescribed, I understand it will NOT be replaced.
Initial: ______ I understand that I will not be given a dosage that is higher than FDA guideline maximum recommended dosage. I understand if I am currently on a higher dosage than the FDA maximum recommended dosage, then my provider may decide to reduce the dosage or change the medication.
Initial: ______ I will not accept or seek similar controlled medication from a health care provider outside of our practice while we are prescribing controlled medication. I understand that I must keep my provider informed of other controlled medications prescribed by other providers including substance use medications like Suboxone/Methadone.
Initial: ______ I understand that office staff is not permitted to refill controlled medications without provider approval. Medication refills request can be made through the patient portal or by telephone during business hours and requested 5-7 days before the prescription runs out.
Initial: ______ I understand that my controlled prescription will only be sent to one pharmacy and can only be transferred one time to another pharmacy. Exceptions will be made if your pharmacy is out of stock of the prescribed medication.
Initial: ______ I agree that I will not use any illegal drug(s) while receiving care and medication from this practice. I understand that any criminal charges for receiving, possession, or selling of illegal substances and/or a controlled prescription will be reviewed by my provider and will result in my discharge.
Initial: ______ I agree and understand that my provider reserves the right to obtain urine drug testing. Drug testing will be required at the discretion of your provider. Initial prescriptions will not be sent to the pharmacy until the drug screen is received. If I fail to obtain drug screen when asked or if the results are inconsistent, I may forfeit the right to continue receiving controlled medication.
Initial: ______ I give permission for my provider to contact any pharmacy, health care providers, or hospital to discuss medications when they feel it is indicated.
I understand that failure to comply with the above conditions will be considered a breach of the contract and may result in the immediate termination of controlled medications and/or termination of care from the practice. All consulting and referring providers will be notified of any questions or suspected noncompliance of this contract.
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Signature Date