1.) Controlled substances are habit forming and can cause physical dependence. Suddenly stopping the medication may cause physical withdrawal symptoms. These symptoms may include flu-like feelings, crawling skin, sleeplessness, irritability, anxiety and even seizures. I understand that I may develop physical dependence from medications. __________ (initial)
2.) Patients with a history of substance abuse, including alcoholism, are at high risk of relapse from certain medications, Patients with a strong family history of substance abuse are also at a high risk for addiction. I understand and agree that I have notified GetWell Health System of any personal or family history of substance abuse, including alcohol abuse. __________ (initial)
3.) I understand that my medications may not be taken more often than prescribed. If you medication is not controlling your symptoms, you must schedule a follow up appointment. You cannot increase your dose. Prescription refills will not be given early under any circumstance. Travel plans during your regular refill appointment time will not result in early refills so please plan accordingly. I understand that if I run out of my medication, I may suffer withdrawal symptoms. __________ (initial)
4.) Obtaining controlled medications from more than one doctor without notifying all physicians who prescribe to you is a felony. The only exception is medication taken during an inpatient hospitalization. You must immediately notify us during your next appointment if you receive pain medications, sleeping pills, tranquilizers, or other controlled medications from any other provider (including emergency room doctors). I understand that I will be dismissed from the practice if I do not notify GetWell Health System that I have received controlled medications from another source. __________ (initial)
5.) Patients are responsible for scheduling and keeping all appointments. I understand that to get refills, I must be seen in the office and that no refills or medication changes will be made after hours or on the weekends. __________ (initial)
6.) I understand that I am receiving medications that are at a high risk of being stolen. I am responsible for protecting these medications and understand that GetWell Health System cannot replace medications that are lost, stolen, or damaged. We also recommend that you file a heft report with local law enforcement agencies. __________ (initial)
7.) I understand that selling, trading, or giving my medications to anyone is illegal. __________ (initial)
8.) I understand that it is the policy of GetWell Health System to perform urine or serum drug test during office visits and randomly at will. I understand that if I refuse or fail to provide a urine sample, I will not be prescribed my controlled medications. I also understand that should GetWell Health System become aware during testing that I am using street or prescription drugs not prescribed to me that it will result in loss of medical treatment with a controlled substance. __________ (initial)
9.) I understand that it is the policy of GetWell Health System to perform random pill counts. I will maintain an active phone number as well as answer and return any missed calls from GetWell Health System immediately. I will notify the office within 24 hours with any changes to my phone number. When called in for a pill count, I understand that I have 24 hours to arrive to the office with my medication in the original pharmacy container with the label intact. Failure to return multiple calls from our office, maintain an active number where you can be reached, or to appear for pill counts will result in loss of medical treatment with a controlled substance. __________ (initial)
10.) I understand that changing the date, quantity, or strength of a medication or altering a prescription in any way is illegal. This includes forging a prescription or provider signature. Our office cooperates fully with local law enforcement and the DEA. Any violation to these laws will result in immediate dismissal from the practice and may be reported to the authorities and local pharmacies. __________ (initial)
11.) I understand that my provider will use his or her medical judgment when deciding what medications to prescribe for my medical care and he or she may choose at any time to change medications, reduce dosage, or stop prescribing a controlled substance if he or she believes it is medically appropriate. Additionally, if I violate this contract, GetWell Health System must consider that I may be abusing or selling medications. IN such instances, doctor-patient confidentiality does not prevent GetWell Health System from providing pertinent information to law enforcement agencies. __________ (initial)