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    HSHS Medical Group Controlled Substance Contract

    Uploaded by

    Dean Olsen
    This is an example of a contract that HSHS Medical Group doctors might use with patients when agreeing to prescribe opiate painkillers.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    HSHS Medical Group Controlled Substance Contract

    Uploaded by

    Dean Olsen
    453 views2 pages
    This is an example of a contract that HSHS Medical Group doctors might use with patients when agreeing to prescribe opiate painkillers.

    Copyright

    © © All Rights Reserved

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    DOC, PDF, TXT or read online from Scribd

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    This is an example of a contract that HSHS Medical Group doctors might use with patients when agreeing to prescribe opiate painkillers.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    453 views2 pages

    HSHS Medical Group Controlled Substance Contract

    Uploaded by

    Dean Olsen
    This is an example of a contract that HSHS Medical Group doctors might use with patients when agreeing to prescribe opiate painkillers.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    You are on page 1of 2

    Controlled Substance Contract

    As a patient being asked to sign this contract, I know that:


    Medications can be addictive. My body may need more and more medication, and it can be hard to stop
    taking this medication. Even while taking my medications as directed, I still may have symptoms.
    Not all of my symptoms may go away with the medication, but it should be better controlled so that I am
    better able to function.
    Pain medication treats my pain but not its causes.
    Medication can cause side effects. It may cause me to be sleepy or slow how I react, or think. These
    side effects can make it dangerous to drive a car or use machines.
    Taking more than the suggested dose of a controlled substance or combining controlled substances with
    other medications, such as drugs for anxiety, muscle relaxants, sleep aids or alcohol can cause serious
    problems including but not limited to: passing out, stopping breathing, and death.
    I may not be given a controlled substance if I am using marijuana, even if it is medical marijuana.
    I agree to submit to a urine drug test at the choice of my provider.
    If my drug test shows positive results for medications other than what I have been given, or shows I am
    NOT taking the medications as prescribed, I will no longer be given narcotic medications.
    My provider may take me off of my medication if I do not follow the medication contract or if he/she
    believes that my being on the medication is harming or not helping me.
    I will get refills of my controlled substance medication from the same pharmacy each time.
    I will only get medications that are given to me by the provider listed below.
    If I break this contract for any reason, I may not have my medications refilled and I may be dismissed
    from the providers practice.
    I may need other medications, treatments and tests to diagnose and treat my pain.
    If my medications are lost or stolen, my provider may not refill them until the due date.
    My Agreement
    My provider and I have talked about my controlled substance medication. I understand that I must
    follow this agreement. If not, this provider or other providers at HSHS Medical Group may not
    prescribe controlled substance medication for me. They may refuse to provide my medical care if I do
    not follow this agreement.
    ________________________________________
    Printed Name of Patient/Authorized Representative

    ________
    Date

    Date of Birth

    ________________________________________
    Signature of Patient/Authorized Representative

    ________
    Date

    Relationship to Patient

    _______________________________________
    Provider Signature

    ________
    Date

    Provider Printed Name

    Last Revised 7/29/16

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