CONTROLLED SUBSTANCES
AGREEMENT
The following
agreement is a sample agreement to be utilized at our organization. This
agreement is not valid unless signed by both the patient and the
physician or physician’s representative and witnessed. This is copyrighted
material.
We, at the Pain Management Center
of Paducah, are committed to doing all we can to treat your chronic
pain condition. In some cases, narcotics are used as a therapeutic
option in the management of chronic pain, which is strictly regulated
by both state and federal agencies. This agreement is a tool to protect
both you and the physician by establishing guidelines, within the
laws, for proper and controlled substance use.
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All controlled substances must come from
the physician whose signature appears below or, during his absence,
by the covering physician, unless specific authorization is obtained
for an exception.
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All controlled substances
must be obtained at the same pharmacy, where possible. Should the need arise
to change pharmacies our office must be informed. The pharmacy
that you have selected is:
- Pharmacy: _____________________________________________________
Phone: _______________________________________________________
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The prescribing physician
has permission to discuss all diagnostic and treatment details
with dispensing
pharmacists or other professionals who provide your health
care for purpose of maintaining accountability.
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You may not share, sell, or otherwise
permit others including spouse or family members to have access
to these medications.
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Unannounced urine or serum toxicology
screens may be requested, and your cooperation is required. Presence
of unauthorized substances may result in your discharge from
the facility.
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I will not consume excessive amounts
of alcohol in conjunction with narcotics, nor will I use, purchase,
or otherwise obtain any other legal or illegal drugs.
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Medications may not be replaced if they
are lost, stolen, get wet, are destroyed, left on an airplane,
etc. If your medication has been stolen it will not be replaced
unless explicit proof is provided with direct evidence from authorities. A
report narrating what you told is not enough.
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If the responsible legal authorities
have questions concerning your treatment, as might occur, for
example, if you were obtaining medications at several pharmacies,
all confidentiality is waived and these authorities may be given
full access to our records of controlled substances administration.
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Early refills will not be given. Renewals
are based upon keeping scheduled appointments. Please do not
phone for prescriptions after hours or on weekends.
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In the event you are arrested or incarcerated
related to legal or illegal drugs, refills on controlled substances
will not be given.
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It is understood that failure to adhere
to these policies may result in cessation of therapy with controlled
substance prescribing by this physician.
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You affirm that you have full right and
power to sign and be bound by this agreement, and that you have
read, understand, and accept all of its terms.
