WHAT YOU SHOULD KNOW:
The medicine your health care provider has talked to you about is called a controlled substance. A controlled substance has the potential to be abused. Your healthcare provider wants you to be safe while you take this medicine. This agreement helps you to know what you should and should not do while taking this medicine. It helps your healthcare provider and you follow the law. It applies to all controlled substance prescriptions this practice gives you.
Note: For children with ADHD, treatment decreases the risk of substance abuse. ADHD medication has the potential for abuse, misuse and addiction if NOT taken appropriately as prescribed.
INSTRUCTIONS:
This agreement is like a contract. Please read all of this agreement first. Then write your initials on the blank lines next to each item. You will sign the agreement on the last page. You may ask any questions you have before signing the agreement. When you sign it, it means you understand everything you have read. It also means all of your questions were answered.
You may decide you do not want to sign this agreement. If you do not sign it your healthcare provider will not be able to give you a prescription for a controlled substance.
Note: initial fields with prefix * may be marked N/A if the form is only for ADHD medication.
USING A CONTROLLED SUBSTANCE SAFELY AND LEGALLY
Carefully Read the statements below.
I will take this medicine exactly how my healthcare provider instructs me to take it.
I am the only person who will take this medicine. I will not share this medicine with anyone.
I will keep this medicine in a place where no one other than me can get it.
I will file a police report if this medicine is lost or stolen. I will tell my healthcare provider and give
the office a copy of the police report. My provider may or may not give me more medicine.
* In most states, driving while taking this medicine (excluding ADHD and wakeful medications) is considered driving under the influence (DUI).
I will call my healthcare provider within 2 days if another healthcare provider gives me a controlled substance. This includes the hospital or the ER.
I might be asked to take a urine or saliva (pee or spit) drug test while I am taking this medicine. I may have to pay for the test.
I may have to bring this medicine to my health provider’s office for a pill count. This means this medicine will be counted by my healthcare provider or another provider in the office.
· This includes notification of certification for medical marijuana and proof of certification must be presented to the office.
· If medical marijuana is started other controlled substances may be weaned or stopped.
If I do any of the following, my healthcare provider may not refill this medicine:
· Take someone else’s medicine.
· Fail to take or use my medicine as instructed by my healthcare provider.
· Use, sell, possess, or transport any illegal drugs or other illegal substances. This includes marijuana.
· Misuse legal drugs or other legal substances. This includes alcohol.
· Try to get a controlled medicine from another healthcare provider.
My healthcare provider checks the PA Prescription Drug Monitoring Program (PA PDMP) in accordance with PA law.
RISKS OF USING A CONTROLLED SUBSTANCE
Carefully Read the statements below.
This medicine may not help me or may help me only for a short time. My healthcare provider will talk with me about what is best for my health condition.
This medicine may have side effects. Some side effects are:
· Feeling dizzy or headache
· Feeling sleepy
· Nausea or throwing up
· Constipation (not ADHD)
· ADHD only: increased heart rate
· ADHD only: decreased appetite
· Itching (not ADHD)
· ADHD only: weight loss
· Trouble concentrating (not ADHD)
· ADHD only: stomach pain
*This medicine may have side effects that cause me harm or injury (NOT FOR ADHD). Some serious side effects are:
· Breathing problems
· Allergic reaction
· Accidents
· Slow to react
· Brain changes
· Trouble concentrating
*I have been told not to do the following activities while taking this medicine (EXCEPT IF ADHD MEDICINE)
· Use heavy equipment or power tools. This includes lawn mowers and chain saws.
· Drive. This includes cars, motorcycles, trucks, ATVs, boats, and other vehicles.
· Work in a high place without protection. This includes working on a ladder or on a roof.
·Take care of people who can't take care of themselves, like a baby.
* I might become tolerant to this medicine (EXCEPT PEDIATRIC ADHD MEDICATION). This means my body might get used to taking this medicine. I might feel like I need more medicine to help me.
* I might become dependent on this medicine (EXCEPT PEDIATRIC ADHD MEDICATION). This means my body might feel withdrawal if I do not take this medicine. Withdrawal might make me feel sleepy, grumpy, or like I have the flu. I might have an upset stomach or have trouble thinking.
* I might become addicted to this medicine (EXCEPT PEDIATRIC ADHD MEDICATION). This means I may "crave" this medicine even when my body does not need it. It can happen even if I have not been addicted before.
I am at higher risk to become tolerant, dependent, or addicted to this medicine if I have been addicted to anything before. I am also at risk if anyone in my family has been addicted before. This includes alcohol or marijuana.
If I feel like I am tolerant, dependent, or addicted to this medicine, I will tell my healthcare provider.
I am at risk for overdose if I take too much of this medicine. Overdose might also happen if I take other medicine or someone else's medicine while taking this medicine. I could die if I overdose.
My healthcare provider might decide I should stop taking this medicine if:
· It is not helping my health condition.
· I have serious side effects.
· I become tolerant, dependent, or addicted. Or, if I overdose.
(Women Only) Taking this medicine while I am pregnant may hurt my baby. My baby could become dependent on the medicine. I will tell my healthcare provider and my OB/GYN if I am pregnant. I will also tell my healthcare provider and my OB/GYN if I think I am pregnant or want to become pregnant.
MY HEALTHCARE PROVIDER AND ME
Carefully Read the statements below.
My healthcare provider will help me to know which medicine is right for me.
I might need to see another healthcare provider to help me with my health condition. Examples are:
· Physical therapist
· Mental health
· Specialist
I will come to every appointment. I might need to be seen in the office every 1 to 3 months while I am taking this medicine. This is to help keep me safe and healthy.
This medicine will only be refilled during my office visit or during regular office hours. It may take the practice 3 business days to refill my medicine.
This medicine will not be refilled early. It may take the practice 3 business days to refill my medicine.
My prescription will be eprescribed to the pharmacy. I understand under federal regulations, that my prescription will not be printed.
I will tell my healthcare provider all of my past and current health history, including:
· Health conditions
· Medicine I use now
· Medicine I have used before
· Alcohol use
· Drug use
· Allergies
I will ask my healthcare provider any questions I have about the medicine I take.
I will treat my healthcare provider and all staff with respect as I will expect to be treated with the same respect.
If there is a legal investigation about me possibly not following the law when using this medicine, I give consent to my healthcare provider to share information as required to follow all city, state or federal laws. When following these laws:
· My provider might share information with law enforcement, a pharmacy the Board of Pharmacy, or other healthcare providers.
· Information might include a copy of this agreement. It may also include my name and Other information that identifies me.
SIGNATURE
My signature below means the following:
· I have read all of this agreement or someone has read it to me. I understand this agreement.
· I have asked any questions I have about this agreement. My questions have been answered.
· I understand I must sign this agreement to receive controlled substances from my healthcare provider.
· I understand if I do not follow this agreement:
· This medicine may be stopped. If it is stopped, my provider may taper the medicine over several days.
· PinnacleHealth Medical Group might decide I can’t be a primary care patient anymore.
· If I am dismissed as a patient because I have not followed this agreement I waive any rights I have to any action against Apple Ridge Family Medicine.
· I understand I will receive a signed copy of this document upon request.