BALZ05 Controlled Substance Medication Agreement

Controlled Substance Medication Agreement

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Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

This agreement outlines the expectations and responsibilities of patients who are prescribed controlled substances as part of their treatment plan at Balanced Mental Health of Arizona. It is designed to ensure the safe, legal, and effective use of these medications.

Please read each item carefully and initial beside each statement to confirm your understanding and agreement.

I agree to take my medications exactly as prescribed and not to change the dosage or frequency without prior approval from my provider. Initials *

I will store my medications in a safe and secure location, out of reach of children, pets, and others. I understand that lost or stolen medications may not be replaced. Initials *

I will not sell, share, or give my medications to anyone else under any circumstances. Initials *

I understand that requests for controlled substance refills will only be considered during scheduled office visits. If my medications are lost or stolen, I agree to file a police report, provide a urine drug screen, and schedule an appointment with my provider. Replacements are not guaranteed. Initials *

I understand that failure to attend or arrive on time for my scheduled appointments may delay or prevent prescription refills. Initials *

I will notify the office promptly of any changes to my address, phone number, or insurance information. Initials *

I agree to sign a release of information (ROI) form to allow communication and coordination of care with other providers involved in my treatment. Initials *

I will inform my provider of all medications I am currently taking and notify them immediately of any new prescriptions or changes to my medication regimen. Initials *

I agree not to obtain controlled substances from any other healthcare provider while under the care of Balanced Mental Health of Arizona, unless it is for a documented emergency. Initials *

I will not use any illicit drugs, including but not limited to fentanyl, heroin, cocaine, methamphetamine, or unauthorized stimulants. Initials *

I understand that controlled medications may pose serious risks during pregnancy. If I become pregnant or plan to become pregnant, I will immediately inform my provider. Initials *

I agree to participate in random urine drug screenings as part of my treatment plan, as deemed necessary by my provider. Initials *

I agree to use a single pharmacy for all controlled substance prescriptions and to notify my provider if this changes. Initials *

I understand that my provider will periodically review the state Prescription Monitoring Program (PMP) database to ensure compliance. Initials *

I acknowledge that violation of any part of this agreement may result in changes to my treatment plan, including tapering or discontinuation of controlled substances, and/or dismissal from the practice. Initials *

By signing below, I confirm that I have read and understand the terms of this agreement and agree to comply fully with all conditions.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Patient/Legal Guardian Signature *