I understand that Dr./PA-C/ARNP (hereinafter referred to as “provider”) is prescribing a controlled substance medication for pain management. This Controlled Substance Medication Agreement is a tool for communication, allowing me to work together with my provider in good faith and for me to understand the importance of this medication. In prescribing a controlled substance medication, my provider is trying to create the best treatment plan for my improvement and management of pain. This requires cooperation, trust and mutual respect. If I cannot agree with the following terms, no controlled pain medications will be prescribed. The failure to follow all terms of this Agreement will result in discontinuing the pain medication and/or dismissal from this orthopedic practice.

  1. I will take the medication exactly as prescribed and I will not change the medication dosage and/or frequency without the approval of my provider.
  2. I will keep regularly scheduled appointments with my provider. If my medication needs to be refilled between office visits I will call the office at least 1 to 2 days before my medication runs out. Refill requests will only be taken on Monday - Thursday from 8:30 am to 4:00 pm and Friday 8:30 am to 3:30 pm. Any request for controlled substance     pain medications after 3:30 pm on Friday will not be considered for refill until Monday morning at 8:30 am. The on-call provider will not refill any pain medications after hours, on weekends, or holidays. If I have uncontrolled pain during a weekend, medical care should be sought from an emergency room or immediate care center.
  3. The controlled substance pain medication prescribed is being given in order to control pain and improve function. If there are any changes to my activity level or physical condition, the treatment may be changed or discontinued. I am responsible for notifying my provider of such changes.
  4. I will be ready to taper or discontinue the controlled substance pain medication as my condition improves. If my condition does not improve, my provider may recommend additional conservative or invasive orthopedic procedures. If my level of pain still does not allow me to taper and discontinue the controlled substance pain medication, I may be referred to a pain management specialist for management of my pain medications.
  5. I agree to act responsibly, including protecting and limiting access to these medications, and to dispose of any unused medication in a proper manner.
  6. I agree to NOT accept or seek controlled substance pain medication from any other physician or health care provider, including my primary care physician, while I am receiving prescribed pain medication from this orthopedic practice. It is essential that only one provider monitor and evaluate my use of pain medication.
  7. If I have another condition that requires the prescription of a controlled substance pain medication (narcotics, tranquilizers, barbiturates, or stimulants), I will be asked to coordinate all medications with that prescribing provider.
  8. It is required that I use a single pharmacy for all prescriptions. I may use a chain of pharmacies with different branches, as the prescription information is available at all branches. This is required to make certain that my medications are known by a pharmacist who is able to evaluate any concerns about interaction of medications.
  9. I understand that lost, stolen or misplaced prescriptions or pills will not be replaced. I am required to act responsibly with my medications. This medication is prescribed for me and only my specific pain needs. To allow others to use my medication is illegal and dangerous. This type of behavior will not be tolerated by my provider and this orthopedic     practice.
  10. I agree that I will not use any other illegal and/or recreational drugs while receiving care and pain medication from this practice. Use of illegal and/or recreational drugs, especially while also taking pain medication, is extremely dangerous and potentially lethal.
Digital Signature
I attest that the above information is correct and to the best of my knowledge. I have read and understand the entire contents of the form and have had the opportunity to ask questions regarding the information of this form.