Controlled Substance Agreement

Patient's Name*
First Last
Patient's Date of birth*
MM slash DD slash YYYY
Patient's Pharmacy*
CONTROLLED SUBSTANCE AGREEMENT

Controlled substance medications can include narcotics, stimulants and sedatives. These medications can carry the risk of dependence, misuse, abuse or diversion. The goal of this medicine is to help control the effects of my or my child’s condition(s), stated below, as much as possible without causing dangerous side effects, and is not curative. To ensure client safety, strict accountability is necessary.

For this reason, you agree to the following policies as needed conditions for the medical providers of this Agency to start and continue the prescription of controlled substances in your or your child’s treatment.

Prescription requests and routine medication questions will be answered within 48 business hours. All medical emergencies must go to the local emergency department or call 911.
The use of*
is only one a part of the treatment for*
Provider that will be my designated provider for this medication.*
I have received medication counseling from my provider which includes the information below regarding safety and agree to the following:
1. All controlled substances must come from your designated provider, unless special authorization is obtained. All controlled substances must be obtained at the same pharmacy, unless the designated provider is notified ahead of time.

2. I or my child will participate in all other types of treatment that they are asked to participate in.

3. I am expected to notify us if I or my child experiences any adverse effects of this medication, and to inform us of any new medical problems or medications.

4. The risks of these medications increase with the use of alcohol or other similar medications, including illegal substances. Do not use alcohol or other substances while taking these medications. For those who are recovering from substance dependence, these medications may cause relapse. For caregivers, if I become aware that my child is using these substances (alcohol or illicit drugs) while taking these medications, I will notify their provider immediately and understand that treatment may be stopped.

5. Per CT state law, prescriptions of this type will be entered into a statewide prescription drug monitoring database.

6. The patient and/or caregiver may not share, sell or otherwise allow others to have access to these medications. I understand that if I or my child does, the treatment will be stopped. I agree to store them in a protected area where they are out of reach of children and safe from theft. I acknowledge that the use of these medications by others could be hazardous or lethal. I agree to safely dispose of unused medication by turning in unused medication to an official drop site.
7. I or my child must not take more medication than prescribed without specific instruction from the provider.

8. I understand that refills of the medication are authorized once every thirty days if the required follow-up office visits are kept. I understand that to obtain a refill, I must call the clinic Monday-Friday during regular office hours at least three days before the refill expires to request a refill.

9. Certain behaviors will require reassessment of, and the possible end of treatment agreed to under this contract. They include but are not limited to: Requests for early refills, replacement of damaged, destroyed, lost or stolen medications or use of multiple pharmacies.

10. This is a trial of therapy, and it will only be continued if there is evidence of benefit. The medication may be discontinued or changed if determined to lack effectiveness or have adverse consequences.

11. In some instances, the medication may be provided as a “bridge prescription” or as a limited supply until a specialist or primary care provider can be acquired.

12. I will sign a release of records form to let the designated provider speak to all other providers that the I or my child receives care from. I will inform the designated provider of all other medicines that I or my child take and notify them of any medication changes, including new medications, as soon as possible.

By signing this document, I agree to, understand, and accept all terms and conditions.
Patient Signature
Today's date*
MM slash DD slash YYYY
Parent/Guardian Signature (if patient is under 18)
Today's date*
MM slash DD slash YYYY
Provider Signature*
Provider Name*
Today's date*
MM slash DD slash YYYY

CONTROLLED SUBSTANCE AGREEMENT