Apex Health - Publicforms

Available Forms

1. NEW PATIENT REGISTRATION FORM 2. NEW PATIENT Medical History 3. HIPAA Release and CONTACT Policy 4. CONTROLLED SUBSTANCE AGREEMENT 5. NEW PATIENT Opioid Dependence Scale 6. Clinic Rules Form 7. FOLLOW UP Opioid Dependence Progress Report

4. CONTROLLED SUBSTANCE AGREEMENT

CONTROLLED SUBSTANCE AGREEMENT

Patient Name *

Patient Date of Birth: *

I understand that I have been prescribed medications that are listed as Controlled Substances by the Drug Enforcement Agency for a medical diagnosis that has not been adequately controlled with other medications and that my function is limited without the use of these medications. I understand that the intent of the medication is to treat a medical condition. *

Intial

I will take the medication only as prescribed *

Initial

I will not take any sedatives, alcohol or other pain medication without the prior approval of my provider. *

Initial

I understand that the medication will be prescribed only by a provider of Apex Health, and only according to the agreed-upon schedule. Prescriptions will be provided only during regularly scheduled appointments. *

initial

I will not seek or accept any Controlled Substance medications other than those prescribed by my doctor. This includes prescriptions from other doctors, medications borrowed or accepted from family or friends, and any illicit or street drugs *

Initial

No refills will be given prior to the scheduled appointment date. If I do not keep my appointment, I will not receive a refill. *

Initial

Two (2) appointment cancellations with less than one working day?s notice or two (2) no-show appointments may constitute grounds for immediate termination of this agreement *

Initial

I understand that my doctor is under no obligation to provide these medications to me, and that she or he reserves the right to discontinue these medications at any time. *

Initial

At my provider's discretion, I agree to cooperate with random drug testing, which may be requested at any time. If I refuse or am unable to comply, I understand this will be considered the same as a ?positive/inconsistent/failed' drug test, and the medication will be stopped. *

Initial

I understand that lost or stolen medications will not be refilled under any circumstances. It is my responsibility to protect and secure any medications. This includes keeping the medication out of the reach of children. A copy of a police report will be required for any lost or stolen narcotics or narcotic prescriptions. *

Initial

I understand that my doctor may require specialist evaluation of my treatment, and I agree to keep appointments when my physician refers me. *

Initial

In addition to the above agreements, I accept the right of my provider?s medical staff to terminate this agreement for any of the following reasons:

1. I seek or obtain any Controlled Substance medication from a source other than my doctor. *

Initial

2. I give, sell, or in any way distribute prescribed medications to any other person(s) *

Initial

3. I in any way attempt to forge or alter a prescription. *

Initial

4. My medical condition declines to the point at which, in the judgement of my doctor, continued therapy with this medication presents a danger to my well-being or safety. *

Initial

5. There is evidence that I am no longer receiving a reasonable therapeutic benefit from the medication, or my doctor determines that I am no longer a good candidate to continue the medication *

Initial

I use the prescribed medication inappropriately such as injecting or snorting it. *

Initial

I understand that by entering my name below, I acknowledge I have read the entire agreement above. I must abide by the rules reviewed above and that failure to abide by these rules may result in the termination of medication prescriptions immediately as well as the services from my provider.

Enter your name: *

Today's Date: *

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