Controlled Medication Agreement Form

  • Nystrom & Associates, Ltd.

    Controlled substance medications have potential for misuse. They are intended to improve function and/or ability to work, and are not simply to feel good. Our providers may not prescribe standing doses of benzodiazepines with stimulant medications. Our providers do not prescribe pain medication or medical cannabis. If you are taking narcotic pain medication, medical cannabis, or are abusing drugs or alcohol, our providers may not prescribe controlled medications to you. If you are pregnant or have certain medical or psychiatric conditions, controlled medications may not be appropriate for you. Your medication provider may request records from other medical providers, permission to talk to family members, drug screens and other laboratory tests, psychological tests, and may review the state controlled medication profile, before starting or continuing controlled medication. Drug screens, laboratory test, and counts of remaining pills may be requested while you are taking controlled medications, and must be completed within 24 hours. Our providers must follow Nystrom & Associates, Ltd. maximum dosing guidelines for controlled medications. I have been told and understand that: I may get addicted to this medication. Your risk for addiction is higher if you have a family history of alcohol or drug addiction. If I need to stop this medication, I must do it in under the direction of a medical provider, including the possible need for admission to a medical detox facility, or I may get very sick. I can be found guilty of Driving Under the Influence (DUI) if taking these medications and driving, even if no alcohol has been consumed. I may not be prescribed controlled medication if I am currently living in a residential chemical dependency treatment center or participating in chemical dependency treatment program. I understand I must remain sober for 12 months minimum after completing a residential or outpatient chemical dependency program before controlled medications will be considered, if at all. Stimulant medications (presently) cannot be called-in or faxed to pharmacies; I must obtain a paper prescription. Unless we cancelled your appointment, no stimulant refills will be given outside of an office visit. I am responsible for scheduling my next appointment so I do not run out of medication between office visits. I will participate in all other types of treatments for my condition that I am asked to participate in. If I am arrested or incarcerated related to illegal drug charges (including alcohol), controlled medications will be stopped and cannot be restarted during the duration of my care at Nystrom & Associates, Ltd. My provider may not grant early refills for any reason (i.e. lost, stolen, damaged) for any controlled medication. If I am taking medical cannabis, methadone, suboxone or other any other narcotic based medications on an ongoing basis, controlled medications will be stopped while I am taking these other medications. Taking stimulants or tranquilizers with these medications can be life threatening and cancel out their effects. If I do not tell my provider about using any drugs or controlled medications on my own or from any other providers, my care will be permanently ended. If I sell, trade, share, fill early, or increase the dose of controlled medications on my own, they will be stopped and cannot be restarted during the duration of my care at Nystrom & Associates, Ltd. If I have an emergency such as severe suicidal thoughts, thoughts to hurt someone else or if I am having a severe drug reaction, I will call 911 or go to the emergency room. I will notify my provider as soon as possible. I will treat the staff at the office respectfully at all times. I understand if I am disrespectful (including but not limited to yelling, foul language, bullying or harassing) to any staff (office and nursing staff or providers) or if I disrupt the care of other patients, my treatment will be permanently stopped at Nystrom & Associates, Ltd. I may be asked to only use one pharmacy to get my medicine. My provider may talk with the pharmacist about my medicines. Drug screens requested by my provider must be completed within 24 hours or will be considered positive. I will inform all my other physicians of the controlled substance medication I am receiving through Nystrom & Associates, Ltd. Likewise, I will inform my Nystrom & Associates, Ltd. medication provider of any other controlled substance medication I receive from another physician.
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