The purpose of this agreement is to prevent misunderstanding about controlled medications you will be prescribed as a course of treatment. This is to help both you and your doctor to comply with the law and safe use protocols regarding controlled pharmaceuticals.
I understand that this agreement is essential to the trust and confidence necessary in a doctor/patient relationship and that my doctor undertakes to treat me based on this agreement. I understand that if I break this agreement, my doctor will stop prescribing these controlled medications. I will not use any illegal controlled substances, including marijuana, cocaine. etc.
I will not share,.sell or trade my medication or prescription(s) with anyone.
I will bring the original container of my previous prescription(s) with me to every office visit.
I will not attempt to, nor obtain any controlled medicines, including opioid pain medicines, controlled stimulants, or anxiety medications from any other doctor.
I agree that refills of my prescriptions will be made only at the time of an office visit or during regular office hours. No refill will be available during evenings or on weekends. The doctors’ office has 24 hours to respond to refill requests, which must come directly from the pharmacy by fax.
I authorize the doctor and pharmacist to cooperate fully with any city, state, or federal law enforcement agency, including the state’s board of pharmacy investigation of any possible misuse, sale or other diversion of my pain medicine.
I authorize my doctor to provide a copy of this agreement to my pharmacy. I agree to waive any application privilege or right of privacy or confidentiality with respect to these authorizations. I agree that I will submit to a urine drug test at least, but not limited to, every three months to determine my compliance with my program and to ensure safety from other drug interactions. Any positive results for drugs other than those prescribed by Compassion Health Services LLC may adversely affect the continuation of any treatment and may prompt for assessment of addictive disorder. The urine drug test will also be sent to an independent lab for confirmation testing.