PATIENT PORTAL

Controlled Substance medications are very useful, but they have a high potential for misuse and are therefore closely controlled by the local, state, and federal government. They are intended to relieve pain and improve function.

to improve my ability to work and function at home. *

to help my condition(s) listed above as much as possible without causing dangerous side effects. *

1. If I drink alcohol or use street drugs, I may not be able to think clearly and I could become sleepy and risk personal injury.

3. If I or anyone in my family has a history of drug or alcohol problems, there is a higher chance of addiction.

Refills

Refills will be made only during regular office hours - Monday through Friday, 8:00am-4:30pm. No refills on nights, holidays or weekends. I must call at least three (3) working days ahead (M-F) to ask for a refill of my medicine. No exceptions will be made. I will not come to Primary Care for my refill until I am called by the nurse.

Prescriptions from Other Doctors

I will keep (and be on time for) all my scheduled appointments with the doctor and other members of the treatment team. *

I will participate in all other types of treatment that I am asked to participate in *

I will keep the medicine safe, secure and out of the reach of children. If the medicine is lost or stolen, I understand it will not be replaced until my next appointment, and may not be replaced at all. *

I will take my medication as instructed and not change the way I take it without first talking to the doctor or other member of the treatment team. *

I will not call between appointments, or at night or on the weekends looking for refills. I understand that prescriptions will be filled only during scheduled office visits with the treatment team. *

I will make sure I have an appointment for refills. If I am having trouble making an appointment, I will tell a member of the treatment team immediately. *

I will treat the staff at the office respectfully at all times. I understand that if I am disrespectful to staff or disrupt the care of other patients my treatment will be stopped. *

I will not sell this medicine or share it with others. I understand that if I do, my treatment will be stopped. *

I will sign a release form to let the doctor speak to all other doctors or providers that I see. *

I will tell the doctor all other medicines that I take, and let him/her know right away if I have a prescription for a new medicine. *

I will use only one pharmacy to get all of my medicines. *

I will not get any opioid pain medicines or other medicines that can be addictive such as benzadiazepines (klonopin, xanax, valium) or stimulants (ritalin, amphetamine) without telling a member of the treatment team before I fill that prescription. I understand that the only exception to this is if I need pain medicine for an emergency at night or on the weekends. *

I will not use illegal drugs such as heroin, cocaine, marijuana, or amphetamines. I understand that if I do, my treatment may be stopped. *

I will come in for the drug testing and counting of my pills within 24 hours of being called. I understand that I must make sure the office has current contact information in order to reach me, and that any missed tests will be considered positive for drugs. *

I will keep up to date with any bills from the office and tell the doctor or member of the treatment team immediately if I lose my insurance or can't pay for treatment anymore. *

I understand that I may lose my right to treatment in this office if I break any part of this agreement. *

Pain Treatment Program Statement

We here at Red Hook Family Practice PC are making a commitment to work with you in your efforts to get better. To help you in this work, we agree that:

We will help you schedule regular appointments for medicine refills. If we have to cancel or change your appointment for any reason, we will make sure you have enough medication to last until your next appointment.

We will make sure that this treatment is as safe as possible. We will check regularly to make sure you are not having bad side effects.

We will keep track of your prescriptions and test for drug use regularly to help you feel like you are being monitored well.

We will help connect you with other forms of treatment to help you with your condition.

We will help set treatment goals and monitor your progress in achieving those goals.

We will work with any other doctors or providers you are seeing so that they can treat you safely and effectively.

We will work with your medical insurance providers to make sure you do not go without medicine because of paperwork or other things they may ask for.

If you become addicted to these medications, we will help you get treatment and get off the medications that are causing you problems safely, without getting sick.

Available Forms

RED HOOK FAMILY PRACTICE CONTROLLED SUBSTANCE CONTRACT

Refills

Prescriptions from Other Doctors

Pain Treatment Program Statement