The Other Medical Clinic Pain Management Agreement The purpose of this Agreement is to prevent misunderstandings about certain medicines you will be taking for pain management. This is to help both me and my provider to comply with the laws regarding controlled (restricted) pharmaceuticals and improve treatment of pain while avoiding abuse. . I understand that this Agreement is essential to the trust and confidence necessary in a provider/patient relationship and that my provider undertakes to treat me based on this agreement. A drug dependence treatment program may be required for continued care if I show signs of addictive behavior. Addictive behavior is continued drug craving and seeking in spite of increasingly adverse consequences and without regard to its intended use. I understand that if I break this Agreement, my provider will stop prescribing these pain control medicines, and may terminate my care. In this case, my provider may taper off the medicine over a period of several days, as necessary, to avoid severe withdrawal symptoms. Some withdrawal symptoms may still occur including irritability, nervousness, abdominal pain, headache and others. I will communicate fully with my provider about the character and intensity of my pain, the effect of the pain on my daily life, and how well the medicine is helping to relieve the pain. I will not use any illegal controlled substances, including marijuana, cocaine, methamphetamine, etc. I will not share, sell or trade my medication with anyone. Prescription alteration and/or selling your medications are a felony and will be reported to the authorities. I will not attempt to obtain controlled medicines, including opioid (narcotic) pain medicines, controlled stimulants, or anti-anxiety medicines from any other doctor or from acquaintances, friends or relatives I will safeguard my pain medicine from loss or theft. Lost or stolen medicines prescriptions will not be replaced: To reduce the instances of medication loss/theft, I will carry only the amount of medication that I will be using while away from home. Given the recent publicity regarding drug use and abuse, it is wise for me to keep the type of medication I am taking confidential. However I pledge to tell any other health provider what medications I am taking, including any controlled substances I agree that refills of my prescriptions for pain medicine will be made only at the time of an office visit OR as mentioned in the Agreement below. No refills will be available during evenings or on weekends. I understand that I may be required to come in for an office visit with my provider before refills are given. I authorize the provider and my pharmacy to cooperate fully with any city, state or federal law enforcement agency, including this state's Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my pain medicine. I authorize my provider to provide a copy of this Agreement to my pharmacy. I agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations. I agree that I may have random blood or urine drug tests ordered to confirm my compliance in my program of pain control. I understand that refusal of such testing is considered an admission of non-compliance. I agree to only see the provider named below for my pain medication. In my provider's absence, the on call physician may refill enough medication until my provider returns. I agree to use the pharmacy indicated below for filling prescriptions for all of my pain medicine I agree that I will use my medicine at a rate no greater than the prescribed rate and that use of my medicine at a greater rate will result in my being without medication for a period of time. During this time I may have symptoms related to abstinence. . I agree that I will submit to a pill count at any time if requested by my provider to determine my compliance with any program of pain control medicine. I agree to follow these guidelines that have been fully explained to me. All of my questions and concerns regarding treatment have been adequately answered. A copy of this document has been given to me. This Agreement is entered into on this ________ day of_______, 200___ Patient signature____________________________ Provider signature___________________________ Witnessed by_______________________________ Pharmacy name_____________________________ Phone #____________________ Addendum Patient will be seen every________ months with refills of #_________ per month in between visits.