Please correct the errors described below.


Controlled medications are very useful but have a high potential for misuse and are closely regulated by both state and federal governments, and are now being monitored by insurance companies and pharmacies as well. Examples of controlled medications include most prescription sleep medications (ie, Ambien, Lunesta, temazepam) and stimulants (ie, Nuvigil, Adderall, Ritalin). The main treatment goal is to improve your ability to function and/or work.

This is an acknowledgement of policy. It does not indicate that you will be asked or required to take controlled substances. If your provider does suggest controlled substances and you agree, this policy goes into affect immediately and is strictly enforced.

1. I will not take any more medication than prescribed unless I speak with my healthcare provider (doctor or nurse) at Sleep Medicine Consultants (SMC) first.

2. I am responsible for my controlled medications. If my prescription or medication is lost, misplaced, expired, or stolen, or if I use it up sooner than prescribed, I understand that it may not be replaced. o There is a $35 replacement fee for each lost paper prescription. o Stolen medications should be reported to the police.

3. I will not request nor accept the controlled substance medication from any other physician, or individual while I am receiving such medication from SMC. The only exception is if it is prescribed while I am admitted to a hospital, or it has been discussed with and approved by my SMC provider.

4. I understand that urine drug testing may be required as part of my treatment

5. Refills of controlled medications:

o SMC requests 5 business days to complete my medication request (but it may be ready sooner), therefore it is important to keep track of my medication and plan ahead. This is especially important prior to a holiday or weekend.

o Refills will be made only during regular office hours, 9 am to 5 pm Monday through Friday, once each month. Refills will not be made at night, on holidays, or weekends.

o Refills will be sent to the pharmacy listed below and I will notify SMC office staff if I plan to change my pharmacy.

6. I understand that if the treatment team feels that I am not taking my medications in the prescribed manner or the medications are not improving my ability to function then my provider may stop my medication in a way that does not cause withdrawal symptoms. 7. I understand that if I violate any of the above conditions, my controlled prescriptions and/or treatments with SMC may be ended immediately. If the violation involves obtaining controlled medications from another individual, as described above, I may also be reported to my primary physician, local medical facilities, and other authorities who monitor controlled substances.

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