Contract for Prescription of Controlled Medication

By Filling out and signing this form, I agree to the following conditions for my treatment or the treatment of my minor child or person whom I have guardianship over with the following controlled medications and dosages:Please list out all controlled substance medications your provider has asked you to include in this contract. Be sure to include doses and the directions of how you take them *

By signing this document you agree to the following:

1. I have read and understand the information in this document regarding the controlled medications addressed in this contract.
2. If I am transferring my care from another provider or practice it is my responsibility to provide prior medical records if requested. If these records cannot be obtained in a reasonable amount of time, the medication(s) will not be continued.
3. My prior records must verify the history I have provided, and my current Provider must agree with the prior treating provider’s rationale for the medication in order for it to be continued
4. My prescription(s) for these medication(s) may not be refillable, pursuant to regulation. Furthermore, these prescriptions can be prescribed or refilled only with written prescriptions, pursuant to regulation.
5. I will only obtain prescription(s) for these controlled medication(s) from the above Provider or the covering provider they designate. I understand that other members of the Provider’s group are under no obligation to provide refills for these medications. I understand that this contract applies to any covering clinician for my regular provider and that this clinician has no obligation to prescribe me the above medications if they deem it to be inappropriate to do so.
6. I will request refills for prescription(s) 3 days before the medication(s) run out in order to allow time to refill. Early refills are not given with the exception of extreme circumstances. I agree to treat the above listed medications like cash. If they are lost, stolen, or destroyed they cannot be replaced. Because of this I will keep them in a safe private place or keep them locked up to prevent theft or damage. (please initial in the box provided to show you understand this rule) *Enter your initials here to show you understand this rule.
7. I will notify the police if any of the above medication(s) are stolen from me. I understand that this notification or the existence of a police report does not mean I will get an early refill of the above listed medication(s).
8. I will inform all my providers of all the medication(s) prescribed to me as well as over the counter products I am using. I will notify all my providers of any changes in my condition. If a provider suggests prescribing any of the above listed medications I will inform them of this contract.
9. If I seek emergency/urgent care I will immediately notify the above Provider of any and all medications ordered or prescribed by the emergency/urgent care provider within 1 day of leaving or discharging the facility. This can be done by calling the office and leaving a voicemail, even on weekends and holidays.
10. If there is any need to change the pharmacy I will notify my Provider in advance and understand that medication refills may be delayed due to this change.
11. I understand that the existence of this contract may be shared with my pharmacy. I also understand that the above Provider may inform my other providers regarding the terms of this contract and the conditions and medication(s) it covers.
12. I also understand that my Provider above may be required to check available state databases to verify my prescription history. Discrepancies or evidence of untruthfulness may result in discontinuation of the prescription and/or my treatment relationship with this Provider and Group.
13. I agree to possible random drug testing as requested by my Provider. I agree that failure to provide a sample in the time frame specified or discrepancies in the test results can result in termination of my care with this Provider and Group.
14. I agree to be truthful and respectful to my Provider and their office staff at all times.
15. I agree to avoid improper use of controlled substances. This includes use of street drugs or deliberate overdosing, selling or trading medication. I understand these actions are dangerous and illegal and will lead to discontinuation of the prescription and my treatment relationship with the Provider and Group. I also understand diversion of these medications is a significant public health problem.
16. I agree to avoid weaning or abruptly stopping medication without notifying my Provider.
17. I understand that mixing these medications with alcohol or recreational drugs is dangerous and I will avoid doing so.
18. (For those who can become pregnant) I understand that if I become pregnant while taking these medications, health risks to my child may exist. I agree to contact my Provider immediately if I become pregnant or I am considering trying to conceive.
19. I understand that these medications are only one aspect of my care. Non-compliance with other care plan recommendations is a violation of this agreement and may lead to discontinuation of the prescription and my treatment relationship with this Provider and Group.
20. I understand my medications can be changed or stopped at any point in my treatment in my Provider’s discretion.
21. I understand these medications can lead to substance abuse and addiction in all persons. I will be truthful about my personal or family history of substance abuse to assist my Provider in protecting my safety.
22. I will keep all appointments with my Provider. If I need to reschedule I will do so in advance so that I can make an appointment before I run out of medication or refills. Prescriptions for the above medications will not be refilled prior to the rescheduled appointment. It is my responsibility to make sure this does not happen.
23. I understand that this agreement is specific to me and my Provider or covering provider and may not be continued if another provider takes over my care.
24. (For parents and legal guardians) If a parent of a minor or legal guardian to a disabled adult is suspected of or found to be taking, sharing, or misusing a patient's controlled medication in any way the patient's clinician is mandated to report this to the appropriate state agency. Additionally this may be grounds for discontinuation of the patient's controlled medication and discharge from Boston Psychiatric Alliance.

By typing your name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.