General Medicine Clinic: Dr C Osuji

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I agreed to take any Controlled Substances exactly as instructed. I am NOT allowed to change details or number of times per day that I take my medication without first talking to my Controlled Substance Provider

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I agreed to only take Control Substances prescribed by Dr. Osuji

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I will not seek Controlled Substances written by another provider or specialist unless I have notified my provider prior to filling the prescription.

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I agree to safe keeping my Controlled Substance prescriptions and medication. I understand that lost, miss placed, or stolen prescriptions or medication will not be replaced.

I will bring in all my Controlled Substance medications in the original pill container to every appointment

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I will bring in all control substance medication?s in their original pill container for random pill count within 24 hours of when requested

I will NOT combine any narcotic medication with consumption of alcohol. Any UDS that is positive for both Control Substances and alcohol will be considered a violation of this contract.

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I will NOT combine any narcotic medication with illegal/street/recreational drugs. Any UDS that is positive for both prescribe controlled substances and illicit substances will be considered a violation of this contract.

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I will be responsible for making and keeping appointments for controlled substance refills at least every three months. I understand that NO refills will be written outside of my appointment and I will NOT contact the office for refills of these medications.

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I will be responsible for having a working phone number which the office will use to contact me about random UDS and pill counts. I understand that once notified by the office, either directly or by voicemail, I will have 24 hours to report, or inability to do so will result in a violation of this contract.

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I understand that not all insurances cover the cost of drug screening and that I may be responsible for my part of the entire bill.

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I understand that I will not receive any controlled substances until my provider has been able to review 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.

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I will not lie or tell miss leading information to my provider

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I will not get angry and make threatening remarks in an attempt to get controlled substances

General Medicine Clinic: Dr C Osuji

Available Forms

Controlled med contract

Patient responsibility