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Contract for Long-Term Controlled Substances Therapy for Chronic Pain and/or Dependence/Addiction

The purpose of this agreement is to protect your access to controlled substances and to protect our ability to prescribe for you. The long term use of such substances as opioids (narcotic analgesics) benzodiazepines, tranquilizers, and barbiturate sedatives is controversial because of uncertainty regarding the extent to which they provide long term benefit. There is also the risk of an addictive disorder developing or relapse occurring in a person with a prior addiction. The extent of this risk is not certain. Because these drugs have potential for abuse or diversion, strict accountability is necessary when use is prolonged. For this reason, the following policies must be strictly enforced and must be adhered to by the patient as consideration for, and as a condition of, the willingness of the physician to treat the patient. - All controlled substances must come from this physician (or in his absence, the covering physician) unless specific authorization is obtained for an exception. Multiple sources can lead to drug interactions. - All controlled substances must be obtained from the same pharmacy. Should the need arise to change pharmacies, you must inform this office. The name and location of the pharmacy must be on file at all times. - You are expected to inform this office of any new medications or medical conditions, and of any adverse effects that you may experience from these medications. - You need to inform other physicians of any medications that Dr. Harris or Rose Mintz is prescribing, Failure to coordinate medications (from all providers) that you are taking must be on file at all times. - The prescribing physician has permission to discuss all diagnostic and treatment details with dispensing pharmacists and other physicians/healthcare professionals for the purpose of full coordination of care as well as accountability for the patient's medication and health history. - The prescribed medications should NOT be stopped abruptly - as an abstinence syndrome will likely develop. - Random urine or serum toxicology screens may be requested and is required. You must leave the sample at the time of the office visit. Prescriptions will not be given until a sample is given. - Presence of unauthorized and/or illegal substances may prompt referral for an assessment for addictive disorder, it also may lead to discharge from this program. -Prescriptions and bottles of these medication may be sought by other individuals with chemical dependency and should be closely safeguarded. If your medication is stolen or lost, it must be reported immediately to this office and to the proper authorities. It is expected that you use the highest degree of care when medications are taken in a vehicle, stored at home, or taken to your place of work. Do not let others know where your medication is kept. - Original containers of the medicatio MUST be brought to each office visit. - Since the drugs may be hazardous or lethal to a person who is not tolerant to their effects, especially a child, you must keep them out of reach of others. - Medications may not be replaced if they are lost, destroyed, left on an airplane, get wet etc. - Early refills will not be given unless there is an emergency or a special circumstance exists and is documented in the chart. This may occur if the physician is out of town, for example. - You must be the one to pick up your prescription (from this office) if it a hand carried prescription unless written permission from you in on file in this office. - If the responsible legal authorities have questions concerning your treatment, all confidentiality is waived and these authorities may be given full access to your records. - If you are a danger to yourself or others, it is our responsibility to report such behavior to the proper authorities. Confidentiality will be waived if there is a concern for your life or if another person's life is in danger. - Renewals are contingent on keeping regularly scheduled appointments. Failure to keep appointments and/or habitual "no shows" are grounds for dismissal from the program and is deemed as "non-compliance." - It should be understood that any medical treatment is initially a trial, and that continued prescriptions are based on the progress and evidence supporting the benefit of treatment. - The risk and potential benefits of these therapies are explained by the physician and other staff members. If you are unclear about an issue or have questions, you are advised to ask immediately. - Cancelled appointments that are not rescheduled within 7 days will be considered as non-compliance and a violation of this contract. - Failure to comply with orders regarding radiology or laboratory will also be considered as non-compliant and a violation of this contract. - It is understood that failure to adhere to any of the policies and procedures may result in dismissal from the program and therapy treatment and/or may result in a referral to other outside sources. YOU MUST BRING YOUR BOTTLES TO EACH APPOINTMENT. YOU MAY NOT SHARE, SELL, OR OTHERWISE PERMIT OTHER PERSONS TO HAVE ACCESS TO YOUR MEDICATIONS. VIOLATIONS OF THIS CONTRACT MAY RESULTS IN DISMISSAL FROM THE PRACTICE AND THIS PROGRAM.

Patient Signature: ______________________

Physician/Staff Signature: _______________

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