Controlled Substance Agreement Form

CONTROLLED SUBSTANCE AGREEMENT FORM

This Controlled Substance Agreement (the Agreement) is entered into on between Patient Name: (Patient), Date of Birth: and Prescriber Name: , representing Practice/Clinic: .

RECITALS

WHEREAS, Patient suffers from a condition for which Prescriber has determined that treatment with one or more controlled substances may be appropriate; and

WHEREAS, Prescriber is willing to prescribe controlled substances to Patient only under the terms and conditions set forth in this Agreement to reduce the risks of misuse, diversion, or adverse outcomes; and

WHEREAS, Patient acknowledges the risks and responsibilities associated with controlled substance therapy and agrees to comply with the conditions of treatment as a material term of continuing prescription.

NOW, THEREFORE

In consideration of the mutual promises set forth herein, the parties agree as follows:

1. PRESCRIBED MEDICATIONS AND TREATMENT OBJECTIVES

1.1 Prescribed medications, dosages, and directions will be recorded by Prescriber and are subject to modification. Current medication(s):

1.2 Treatment goals and measurable objectives include:

2. PATIENT RESPONSIBILITIES

Patient understands and agrees that continued prescribing of controlled substances requires strict adherence to the following obligations:

a) Use medication only as directed and do not alter dose or frequency without prior consultation with Prescriber. Patient initials:

b) Obtain controlled substance prescriptions only from Prescriber or as authorized in writing; do not seek multiple prescribers. Patient agrees:

c) Fill prescriptions at a single pharmacy when feasible. Preferred pharmacy name:

d) Store medications securely and prevent access by others; report lost or stolen medications immediately to Prescriber and law enforcement. Patient acknowledges:

3. MONITORING AND TESTING

3.1 Patient consents to periodic monitoring including but not limited to urine drug screening, blood tests, pill counts, and review of prescription records maintained by pharmacies and relevant prescription monitoring programs. Patient consents:

3.2 Frequency and timing of testing will be determined by Prescriber according to clinical judgment and may be random. Patient agrees that refusal to submit to testing is a material breach permitting discontinuation of controlled substance therapy.

3.3 A confirmed positive test for unauthorized substances, evidence of diversion, tampering with samples, or inconsistent results may result in taper, referral for addiction evaluation, discontinuation of controlled substances, or other appropriate actions.

4. PRESCRIPTION AND REFILL POLICIES

4.1 Prescriptions will generally not be replaced for lost or stolen medication without a police report and at Prescriber's discretion. Refill timing will follow documented schedules; early refill requests will be denied except in documented emergencies.

4.2 Maximum daily dosage or limits (if clinically indicated) will be specified here:

5. COORDINATION OF CARE

Patient authorizes Prescriber to communicate with other health care professionals and pharmacies regarding controlled substance therapy, including the release of relevant medical records necessary for safe prescribing and monitoring. Patient authorizes:

6. TERMINATION OF THERAPY

Prescriber may discontinue controlled substance therapy if Patient materially breaches this Agreement, if risks outweigh benefits, or if Prescriber determines discontinuation is clinically indicated. If therapy is discontinued, Prescriber will take reasonable steps to taper medications and provide emergency care as needed.

7. NOTICES

Notices required under this Agreement shall be delivered to the addresses provided below. Patient address:

Prescriber/Practice address:

8. AMENDMENT, WAIVER, COUNTERPARTS

This Agreement may be amended only by written instrument signed by both parties. No waiver of any provision shall be effective unless in writing and signed by the party granting the waiver. This Agreement may be executed in counterparts, each of which is deemed an original.

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Agreement shall be governed by and construed in accordance with the laws of the State specified by Prescriber in the medical record as the applicable jurisdiction. This document constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements and understandings. If any provision of this Agreement is held invalid or unenforceable, the remaining provisions shall continue in full force and effect.

10. MISCELLANEOUS

Patient acknowledges receipt of counseling regarding the risks, benefits, and alternatives to controlled substance therapy, including the risk of dependency, overdose, and interactions with other medications or substances. Patient has had an opportunity to ask questions and has received satisfactory answers.

Emergency contact name and phone:

By signing below, Patient and Prescriber acknowledge that they have read, understand, and agree to comply with the terms of this Controlled Substance Agreement.

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