Controlled Substance Policy
Initial visits: If the prescription can be verified as filled within the last 30 days through the Prescription Drug Monitoring Program (PDMP), then the prescription can be refilled based on the provider’s discretion.
Subsequent visits: Pt. will need to be seen monthly by the provider, this can be telehealth or in person visits based on the provider’s discretion.
Missed visit: The medication (s) will not be refilled until your next visit.
Stolen medications: A police report must be made and a copy brought to your appointment in order to receive a refill.
Lost/Damaged medications: These will not be refilled until the next scheduled refill date. It is the patient’s responsibility to keep the medications in a safe location.
Pill Counts: the provider may request your original prescription bottles at any time for a pill count, the patient must produce the original medications and prescription bottles when requested by the provider.
Drug Screens: Every 3 months and as thought necessary by the provider. A failed drug screen is either a substance that is illegal and shows up on the screen or if the medication you are taking does not show up in the screen. If a drug screen is failed, no further controlled substances will be filled by the practice.
General Policies
Pharmacy: One pharmacy will be used for both controlled substances and non-controlled substance medications.
Have all of your medications available at every visit for verification and medication reconciliation.
If you cannot attend a scheduled appointment, at least 24 hour notice is necessary to avoid being considered a “No Show.”
Three (3) “No Shows” will result in termination from the practice.
Consent to Treat:
I am consenting to treatment by the providers and staff at Nurse Practitioner Services of Michiana (NPS). I consent taken blood tests and performance of any procedures deemed necessary in the course of my workup and diagnosis, whether or not related to presently known conditions, if my medical attendants find these necessary or advisable during the course of evaluation or treatment in for management of any complications that arise or otherwise. I have fully and completely disclosed my medical history, including allergies, blood conditions, prior medications or drugs taken, and reactions I have had to anesthetics, medications or drugs. I consented the administration of such drugs, medications or anesthetics as may be necessary or advisable by in the providers at NPS. I understand that medications may not eliminate all of the symptoms and the medications or treatments given may cause severe reactions or even shock, and that no guarantees to the contrary have been made to me. I understand that medications or treatments in a small number of cases, may cause bodily reactions or complications, requiring additional measures and treatment, which I request and to which I consent. I realize there are inherent risk of minor or major complications and then the procedures including pain, infection, and worsening of symptoms. I understand that any questions I have will be answered by my provider and I will address such questions before they leave. I agree to make no claims against the staff or providers at NPS for complications which may occur, except in the event of gross negligence on their part. If I should make any unwarranted claims, I agree to be responsible for the payment of all cost and attorneys fees incurred by the staff and providers and to post bond in advance of such sums. I further understand that the medical practice of the providers is to be judged according to the standards reasonably acceptable to other similarly experience providers practicing in similar facilities in the United States. I will follow instructions given to me by the providers at NPS and will take responsibility for my outcomes that occurred due to my not following the instructions will hold NPS harmless for any poor outcome due to my not following the instructions and advice given by the providers.
I certify that I have read and fully understand the above and informed consent and that I agree in light of the consent to treatment at NPS.