Controlled Substance Agreement

My doctor / advanced practice nurse, and/or the staff of Indiana Health Group (IHG) have explained the potential risks and benefits of the controlled substance medications that have been prescribed for me.

My medications are to be taken ONLY as prescribed. I must discuss any medication changes during an office visit with my doctor prior to making any medication changes. I understand that if I change dosages without supervision, I could overdose, withdrawal, or potentially experience fatal consequences

I agree to notify IHG immediately if I have any type of side effects from my medications.

I agree to make my provider aware of all medications I am taking, especially any other controlled substances as well as the names of the health care providers prescribing these other medications.

I will avoid drinking alcohol and the use of illicit/illegal drugs while taking controlled substances. I understand the risks of combining alcohol and/or illegal substances with these medications.

I understand that there is a risk of addiction to controlled substances.

I agree that I will NOT share or sell my controlled substances as I understand this is against the law.

I understand that random urine and/or saliva screens may be requested at any time and are a routine part of office procedure for all people taking controlled substances. I understand that if I fail to take a drug screen, I am in violation of this agreement. I understand if my drug screen is negative for the medications prescribed, I will be in violation of this agreement.

I understand that I may be asked to bring in my controlled substance prescription bottles at any time for a pill count. If I fail to bring my bottles in that this is a violation of this agreement.

I will safely store my medications so that my medications are not stolen or lost. I will store my medications out of the reach of children or other family members. I understand that my medications will NOT be replaced if lost, stolen, fall into the toilet, are eaten by pets, left on an airplane, or any other reason.

I understand that there are NO early refills. If I run out my medications early due to overusing them, I may be at risk for withdrawal symptoms that could put my life in danger. I understand that I may have to be hospitalized to prevent life-threatening withdrawal symptoms.

I understand that refills of controlled substances will ONLY be given if I keep my scheduled appointment.

I understand that I, not my pharmacy, must call at least 3 days prior to needing a refill on my controlled substances to allow adequate time to process the refill request.

I am aware that Indiana Health Group does not accept refill requests from my pharmacy.

I understand that while taking controlled substances, I must be seen on a regular basis for follow up appointments, typically every 1-6 months but specifically at a frequency as directed by my provider. If I miss an appointment without notifying my provider, my medication may be lowered or stopped.

I understand that multiple missed or cancelled appointments could result in termination from the practice.

I understand that it is my responsibility to tell my provider if I am, or having reason to believe I am pregnant, as these medications can cause serious harm to an unborn fetus.

I will treat the entire staff of Indiana Health group with respect. Rude, disruptive, physical/verbal abuse will result in immediate termination from the practice.

I understand all statements above, the goals of treatment, potential risks, and safety policies as outlined above.

I understand that my provider may lower and/or stop my medications if there is no improvement in my symptoms, if there are significant side effects.

I understand that I must comply with my treatment plan and that any violation to the terms of this agreement. Failure to do so may result in: Controlled substances no longer be prescribed by any provider at IHG and /or potential termination from the practice.