Controlled Medication Management Agreement
Name: Date of Birth:
The purpose of this agreement is to prevent misunderstandings about use of these medications and the responsibilities inherent with the use of this category of medications (controlled substances). This agreement helps me, my prescribing physician and my pharmacy comply with state and federal laws regarding controlled substances. I understand that this agreement is essential to the trust and confidence necessary in a physician/patient relationship. After careful discussion of the risks, benefits, and alternatives with my physician, I agree to be treated with the following controlled medication(s):
Medication(s):
I will communicate fully and on a timely basis with my physician about the intensity of my symptoms, their effects on my daily life, the effectiveness of the medication in relieving my symptoms, and any significant side effects that occur. This includes keeping the scheduled appointments with my designated physician. I understand that evidence of improved functioning is a requirement of continued treatment. If I am unable to tolerate any controlled medication or it is ineffective, I will bring in any unused medication to my physician for proper disposal.
I understand that this medication is intended for my personal use only and that any sale, trade, or sharing of my medication(s) is prohibited by law. Alteration of a prescription is also prohibited by law. I agree that I will use my medicine at a rate no greater than the prescribed rate and that the use of my medicine more often than prescribed will result in my being without medication for a period of time. I will safeguard my medicine from loss or theft. Any lost, misplaced, stolen, destroyed, altered, or otherwise missing prescriptions or pills will NOT be replaced.
I am aware that I should avoid use of illegal drugs. I will not attempt to obtain any controlled medications from any other source. I may be asked to provide blood or urine for a drug screen. If this screen is positive for controlled medications which have not been prescribed for me or for illicit drugs or if I refuse to comply, I understand that my physician may decline to prescribe any controlled medications until this issue is resolved.
I will inform any other physician involved with my medical care of this agreement and the medications I am taking, including in hospital and emergency department settings.
I understand that refills of my prescriptions will be made only by my physician at the time of an office visit or during regular weekday clinic hours with five business days advance notice. No refills will be available during evenings, weekends, or over breaks when CFD is closed. I agree to use one pharmacy (see below) for filling my prescriptions. If I have to change pharmacies, I will notify my physician.
Pharmacy:
Address:
I understand that my physician and my pharmacy will cooperate fully with any city, state, or federal law enforcement or regulatory agency in the event of any possible misuse, sale, or other diversion of my medication or alteration of my prescription.
I understand that if I break this agreement, my physician will stop prescribing the medication(s), with the option to taper off the medication to avoid withdrawal symptoms if this is necessary. I also understand that a drug dependence treatment program may be recommended.
I agree to follow these guidelines. They have been fully explained to me. Any questions and concerns regarding this agreement have been adequately answered.
This document is being signed by: ClientPersonal Representative, see below
If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.
Full legal name of Personal Representative:
Relationship to client:
Definition of Personal Representative:For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.
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Document Name: Controlled Medication Management Agreement
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