Narcotics Agreement Form Specialists & Anesthesiologist in Twin Falls

The purpose of this agreement is to protect your access to controlled substances and to protect our ability to prescribe for you. Long term use of controlled substances is controversial due to the uncertainty regarding the extent to which they provide long-term benefits. There is also the risk of developing an addictive disorder, but the extent of this risk is unknown. Because these medications have potential for abuse and diversion, strict accountability is necessary when use is prolonged. For this reason the following guidelines must be agreed upon by you, the patient, before the provider will consider the initiation or continuation of prescribing controlled substances to treat your chronic pain:Initials ______ Medications will be prescribed on a regular basis during predetermined office visits. In some cases, the physician or physician assistant may require medication to be filled on a weekly basis.
______ Narcotic prescriptions must ONLY be prescribed by a Southern Idaho Pain physician or physician’s assistant and may not be prescribed by another physician, dentist or surgeon. All previous narcotics prescribed by a physician, here or elsewhere, must be discarded upon entering into this agreement with our office. Taking narcotics that are not currently prescribed are grounds for discharge from our office.
______ Medications will be taken ONLY AS PRESCRIBED without change unless it has been discussed with the provider first.
______ Medications and prescriptions may be sought by other individuals with chemical dependency and should be closely safeguarded. It is expected that you will take the highest degree of care with your medications and prescriptions. They should not be left where others might see or otherwise have access to them. You will not share, sell or otherwise permit others to have access to your medications.
______ Prescriptions will not be filled earlier than prescribed and no prescriptions will be prescribed over the phone. Lost, stolen, destroyed or damaged medications will not be replaced.
______ The patient is not to use alcohol while taking narcotic medication nor use illegal drugs.
______ Your cooperation is required with unannounced urine or serum toxicology screens which will be randomly requested. Presence of unauthorized substances or absence of prescribed medications may prompt adjustments in treatment, monitoring or termination of treatment by this facility.
______ The patient is also instructed that while taking these strong medications, he/she should not operate heavy equipment, drive a car or engage in any activity which potentially could be hazardous to the patient’s safety or the safety of others.
______ The patient is to have prescriptions filled at ONE PHARMACY ONLY which is to be listed below. Any changes in this status must be reported to the office immediately to make amendments in the chart.
______ Charges for random drug screens are solely the responsibility of the patient. If the patient has insurance it will be billed. Patients without insurance will be given a cash pay discount when payment is made in full at time of service.

By signing below, the patient agrees to all guidelines listed above. Failure to follow any of the above guidelines may result in discharge from this practice. The provider and/or patient may cancel this agreement at any time. If the patient chooses not to sign this agreement, narcotic prescriptions will not be prescribed by this practice.
A copy of this will be forwarded to your primary care provider and the pharmacy you list below to insure compliance.