Controlled substances agreement

Controlled substances are only written after patient provider relationship has been established for 3 months, urine drug screen and other laboratory testing completed, risk profile assessed, patient education, knowledge, and understanding completed.

Controlled substances are not provided until an in person appointment has been completed at the appropriate location for the state the patient is located. These being either Everett, Washington, or Chicago, Illinois. In person appointments will be required yearly for any controlled substances.

Per Illinois prescribing mandates, benzodiazepine prescriptions cannot be written for treatment beyond 30 days.

Provider reviews the state prescription monitoring program for controlled substance history prior to writing any controlled substance. Patient is required to disclose any controlled substances prescribed in the past year, if any new controlled substances are prescribed, the prescriber, indication, and duration of treatment. If this is not disclosed and is discovered, this will lead to discharge from the practice.

Patient agreements

I agree:

• I am taking a medication with potential harmful side effects. I reviewed these side effects with my provider.
• I will obtain controlled medication from one provider and will fill the medication at one pharmacy. I understand that I may not obtain controlled medication from multiple sources.
• I will take the medication exactly as prescribed and not change the medication dosage or frequency on my own.
• I will not use controlled substances concurrently, to avoid risk of adverse reaction or death.
• I will keep my medication and prescriptions in a secure location. Lost, stolen, or misplaced prescriptions or medications will not be replaced.
• I will not sell or share my medications. I understand to do so is a felony and that medication that is safe and effective for me can cause dangerous side effects for another person.
• Early medication refills will generally not be authorized and medication extensions will not be granted when I am due for office follow-up. Disrespectful, aggressive, or threatening behavior when requesting medication refill is unacceptable.
• I will not abuse alcohol or drugs, including marijuana or opioid pain medications, while taking this medication.
• I will provide blood or urine drug screens and other diagnostic testing in the judgement of the provider. This test will be completed within 24 hours of test being ordered. Test will be completed using Labcorp services.
• I will bring in my bottle of pills for pill counts, if asked.
• I will attend regular follow-up appointments as directed by the provider.
• My provider may decide to stop my controlled medication due to other mental health or medical issues.
• Controlled medication may only partially treat my condition. I will participate in other referrals or treatments with my provider recommendations for management of my mental health condition(s).

Termination of Agreement

If I am unable to adhere to the above treatment agreement, or if my provider decides that this medicine is hurting me more than helping me, this medicine may be stopped by my provider in a safe way. I have talked about this agreement with my provider and I understand and agree to the above rules.

Provider Responsibilities

As your provider, I agree to perform regular checks to see how well the medicine is working. I agree to provide mental health care for you even if you are no longer receiving controlled substances from me.