FOR MORE INFORMATION REGARDING OPIOID AWARENESS AND NATIONAL HEROIN AND OPIOID AWARENESS WEEK, PLEASE VISIT:
NEW PATIENT AND PHYSICIAN COLLABORATIVE AGREEMENT
Each new patient we serve must review and sign the following collaborative agreement prior to proceeding with narcotic treatment at Commonwealth Pain & Spine. This agreement is required to comply with the law regarding controlled pharmaceuticals and to prevent any misunderstandings about any treatments patients receive.
Because a CP&S physician may be prescribing such medication as part of your plan of care, you must agree to the following:
1.I understand that the main goal of treatment is to improve my ability to function or work. In consideration of this goal and the fact that I am being given potent medication to help me reach that goal, I agree to help myself by following preventive and better health habits such as: exercising regularly, losing weight as directed by a physician, and abstaining from the use of tobacco, alcohol and illicit drugs. I will also participate in physical therapy as prescribed.
2.I agree to submit to a blood, urine or saliva test, if requested by my provider, to determine compliance with my program of pain medication and I waive privacy rights.
3.I understand that my first office visit may be a consultation only and no pain medication given at that time if further investigation and/or testing are deemed necessary.
4.I understand that I may be called at any time to bring all prescribed medication for a mandatory pill count within a specified time period (usually 24 hours- but typically same day).
5.I agree that I will use my medications ONLY as prescribed by my doctor. I understand that any change to my prescriptions will require an office visit. I understand that self-medicating is not tolerated. No refills will be made during evenings or weekends. I will call at least 24 hours, but no more than 48 hours before my medications run out to arrange for refills.
6.I will not use any illegal substances, including marijuana, cocaine, methamphetamines etc.
7.I understand that lost or stolen medication or unfilled prescriptions WILL NOT be replaced, and I will safeguard my medication from theft.
8.I understand that I will follow the guidelines on properly disposing of controlled substances that will be explained to me by clinical staff. I will not discard, flush, give away or in any way lose control of my medications.
9.I will not share, sell or trade my medications with anyone.
10.I will not alter the form of the medication nor will I take the medication in a route other than as prescribed by my provider.
11.I will not attempt to obtain controlled medication from any other provider, nor will I borrow or buy medication from any other person. (with the exception of certain benzodiazepines which are not prescribed by this practice)
12.In the event of an emergency, if I do obtain controlled substances from another provider, I understand I am required to disclose this information to CP&S within 48 hours of discharge or emergency service. I understand it is my responsibility to make sure CP&S is notified of any such treatments and that I am to check with staff before combining any pain medication with the prescriptions CP&S provides me.
13.I will notify CP&S of any change in name, address or phone number. I understand that I must at all times have an updated phone number with my provider. I cannot be on dangerous medications, such as opioids, if my provider cannot reach me in a reasonable period of time (usually considered within 24 hours of the initial attempt). I agree to return any phone call from CP&S within 24 business hours.
14.I authorize my provider to investigate fully any possible misuse of my pain medication using any city, state or federal law enforcement agency, including this state’s Board of Pharmacy.
15.I understand that any follow-up appointment may be scheduled with a Licensed Nurse Practitioner or Physician Assistant. Additionally, I understand that refusing to see one of CP&S providers will likely result in my no longer being able to be treated by the practice.
16.Patient has designated one and only one preferred pharmacy. Once a prescription has been filled, all questions regarding that prescription should be directed to that pharmacy. Our practice will only fill with this pharmacy.
17.I understand that CP&S does not mail narcotic prescriptions under any circumstances.
18.I understand that with any controlled substance that is prescribed to me there are inherent risks, namely;
i.loss of efficacy over time, symptoms of withdrawal if abruptly stopped, and addiction;
ii.medication taken in excess (this is different for everyone – ranging from the prescribed dose to taking more than prescribed or combining with other controlled substances or even alcohol) may result in respiratory suppression or failure or death;
iii.sedation, loss of function, impairment may also occur – I agree not to drive while under the influence of any prescribed controlled substance;
iv.constipation, allergic reaction, itching, nausea and dry mouth are also common side effects;
v.my immune system may be suppressed and my hormone levels may decrease over time while being on chronic opioids.
19.I understand that the combination of controlled substances and alcohol are contra-indicated; the combination may result in serious harm or even death.
20.I understand that non-professional or inappropriate behavior toward any CP&S staff, affiliate or provider will not be tolerated. I agree to be respectful to other patients I may encounter in the waiting room, lobby, hallways, etc. I understand that I may not loiter in the parking lot of any CP&S location.
21.I understand that CP&S providers utilize tests to determine the best option for my care. My unwillingness to complete the tests requested may result in being released from further care with CP&S.
22.I understand that non-compliance with my pain management treatment plan may result in providers’ inability to properly treat my symptoms and could cause symptoms to worsen or become life threatening.
23.I understand that I may be released from this practice for missing appointments or cancelling/rescheduling appointments with less than 24-hour notice.
24.I agree that the goals of pain management have been explained to me as to what is considered appropriate and reasonable and that alternative treatment plans, outside of use of controlled pain medications, have been made available to me. I have agreed to proceed with pain management after a full explanation of the risks and benefits. I understand if I break this agreement, it will result in a change in my treatment plan, including safe discontinuation of my opioid medications when applicable or complete termination of the provider/patient relationship.
I understand that, if I violate any of the above conditions, my controlled substance prescriptions may be immediately terminated. If the violation involves obtaining controlled substances from another individual, or providing controlled substances to another individual, I may also be reported to my other healthcare providers, medical facilities and law enforcement officials.
I have read this contract and have also been informed regarding psychological physical dependence to controlled substances.