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Controlled Substance Agreement Template

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Created by:

(letterhead/logo of company/facility if available)

[Provider.Company][Provider.FirstName][Provider.LastName]

[Provider.Phone][Provider.Email]

[Provider.StreetAddress][Provider.City]

[Provider.PostalCode][Provider.State]

Treatment agreement for [Controlled Substance.Name]

This agreement is in place to ensure that patients and caregivers have clear communication and safe, effective procedures when patients use[Controlled Substance.Name].

Effectiveness

For most patients with (type of condition being treated),[Controlled Substance.Name] is effective at (treatment result). However, it is possible [Controlled Substance.Name] will not work well for you or your (symptoms).

Safety

Most people can take these drugs safely, but some people do experience side effects. (See below)

Side effects

Most patients do not have serious side effects or drug interactions. Unfortunately, some do experience side effects and must stop the medication(s). Common side effects include (describe side effects typical to this controlled substance). Uncommon but potential side effects include (describe uncommon side effects of this controlled substance).

Goals

The goals of this treatment are to:

(These are sample goals and should be replaced with specific goals relevant to the patient and treatment plan)

  1. Decrease your pain.

  2. Increase your ability to move freely and rehabilitate your knee injury.

Alternative treatment options

(These are sample options and should be replaced with specific options relevant to the patient and treatment plan)

  1. Surgery

  2. Rehabilitative physical therapy

  3. Medications

What you need to do

(Some of these are sample actions and should be replaced with specific actions relevant to the patient and treatment plan)

  1. Use your medications ONLY as directed by your medical provider.

  2. Realize that (controlled substance) is only one part of treatment.

  3. Maintain activity every day and try to consistently increase activity level.

  4. Work with your provider and follow treatment recommendations in addition to taking prescribed medications.

Patient responsibility

1) I agree to take any Controlled Substances exactly as instructed. I will NOT change the dose or frequency I take my medication without first talking to my Controlled Substances Provider. _____ (initial)

2) I agree to only take Controlled Substances prescribed by [Provider.Company] _____ (initial)

3) I will not take Controlled Substances prescribed by another provider unless I have notified my initial provider prior to filling the prescription. _____ (initial)

4) I agree to safe and secure storage of my Controlled Substance medications and prescriptions. I understand that lost, misplaced, or stolen prescriptions or medications will not be replaced. _____ (initial)

5) I will bring all of my Controlled Substance medications in their original storage container to every appointment with my provider. _____ (initial)

6) I will bring all Controlled Substance medications in their original container for random pill counts within 24 hours of a formal request. _____ (initial)

7) I will NOT combine any prescribed Controlled Substances with alcohol consumption. Any urinary drug screening positive for both alcohol and Controlled Substances will be considered a violation of this agreement. _____ (initial)

8) I will NOT combine any prescribed Controlled Substances with illegal/street/recreational drugs. Any urinary drug screening that is positive for both illicit substances and prescribed Controlled Substances will be considered a violation of this agreement. _____ (initial)

9) I will be responsible for scheduling and keeping appointments for Controlled Substance refills at least every (number) month(s). I understand that NO refills will be written outside of my appointment, and I will NOT contact the office for refills of these medications outside of an appointment. _____ (initial)

10) I will be responsible for having a functional phone number that the office will use to contact me about random urinary drug screening and/or pill counts. I understand that once contacted by the office, either directly or by voicemail, I will have 24 hours to report, or my inability to do so will result in a violation of this agreement. _____ (initial)

11) I understand that not all insurance providers cover the cost of drug screening and that I may be responsible for part of or the entire amount owed. _____ (initial)

12) I understand that I will not receive any Controlled Substances until my provider has reviewed my medical records. If I am a new patient, I understand that it is my responsibility to ensure my medical records have been obtained from my previous provider. _____ (initial)

13) I will not lie or tell misleading information to my provider or any of the (name of medical facility) staff. _____ (initial)

14) I will not get angry with or make threatening remarks to my provider or their staff in an attempt to get Controlled Substances, and I realize that doing so could result in a violation of this agreement. _____ (initial)

Provider responsibility

1) I will provide the best possible evidence-based care for your condition based on the type of symptoms you have. _____ (initial)

2) I will assist in setting functional and symptom control goals with you. _____ (initial)

3) I will perform a random drug screen at least once a year (possibly from blood, urine, and/or saliva). _____ (initial)

4) I will only refill controlled substances at your scheduled medication refill appointments. _____ (initial)

5) I will consistently assess the risk/benefit/safety of your medications, including:

a. Side effects _____ (initial)

b. Functional abilities _____ (initial)

c. Symptom control _____ (initial)

Consequences of NOT adhering to any part of this agreement:

1) Our providers/office:

a. Will not prescribe any controlled substance for you. It will be at the provider's discretion to decide if tapering of medication will be given. _____ (initial)

b. May refer you for drug abuse treatment. _____ (initial)

c. May stop providing medical care for you. _____ (initial)

Consequences of NOT signing this agreement:

1) We will not prescribe controlled substances for you. _____ (initial)

Should you be removed from our practice due to a breakdown of provider/patient communication, your provider agrees to provide 30 days of care from the date of discharge. This might not apply to the prescription of Controlled Substances if the reason for discharge was a violation of this agreement.

Signature
MM / DD / YYYY

Signature
MM / DD / YYYY

[Patient.FirstName][Patient.LastName]

[Patient.Title]

[Provider.FirstName][Provider.LastName]

[Provider.Title][Provider.Company]

Controlled Substance Agreement Template

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