All controlled substances used to treat my mental health condition must come from my provider at IShine Behavioral Health or during his or her absence, by the covering provider, unless specific written authorization is obtained from the office for an exception. Exceptions may be made for emergency acute care.
I will inform my physician of any new medications or medical conditions, and if any adverse effects I experience from any of the medications that I take.
I will not allow anyone else to have, use, sell, or otherwise have access to these medications. The sharing of medications with anyone is forbidden and is against the federal law.
I understand that controlled substances may be hazardous or lethal to a person who is not tolerant to their effects, especially a child, and that I must keep them out of reach of such people for their own safety.
I understand that tampering with a written prescription is a felony, and I will not change or tamper with my doctor’s written prescription.
I am aware that attempting to obtain a controlled substance under false pretenses is illegal.
I will take my medication as instructed and prescribed, and I will not exceed the maximum prescribed dose. Any change in dosage must be approved by my provider.
I agree not to alter my medication in any way and I will take my medication whole. It will not be broken, chewed, crushed, injected, or snorted.
I will cooperate with unannounced urine or serum toxicology screenings as may be requested, as well as any random pill counts of medication. Failure to comply may result in immediate discharge from the practice.
I understand that the presence of unauthorized and/or illegal substances in the toxicology screenings may prompt referral for assessment for a substance use disorder or discharge from the practice.
I will not share my medication with anyone. I will store my medication in a secure location to prevent it from being lost, stolen, or unintentionally used by others.
I understand that medications may not be replaced if they are lost, damaged, or stolen. If any of these situations arise that cause me to request an early refill of my medication, a copy of a filed police report or a statement from me explaining the circumstances may be required before additional prescriptions are considered. If I request an early refill secondary to lost, damaged, or stolen prescriptions twice within a year, I may be discharged from the practice.
I understand if legal authorities have questions concerning my treatment due to concern for any possible sale, misuse, or diversion that my physician will cooperate fully with any law enforcement agency and these authorities may be given full access to my records of controlled substance administration.
I understand that my physician will use the resources available to verify my compliance with this agreement including, but not limited to, my pharmacy and the Controlled Substances Database.
I understand that failure to adhere to these policies and/or failure to comply with the physician’s treatment plan may result in cessation of therapy with the controlled substance prescribed by this physician and/or a referral for further specialty assessment, as well as possible discharge from the practice.
As Policy of IShine Behavioral Health, I am required to be seen in office visit minimum of twice a year or more if provider requires more frequent in office appointments.