Recognizing that a small group of chronic pain patients benefit from chronic, or long term, narcotic usage; this contract is enacted to insure the safe and proper use of these controlled substances. By signing this contract, you agree to meet your patient responsibilities while on these medications.
Any infraction of the following stipulations is a breach of this contract and the patient can be considered discharged from this prescribing agreement.
- The patient agrees to have psychological evaluation for potential addictive behavior
- The patient denies any history of drug or alcohol abuse/addiction
- The patient denies history of conviction for drug related offenses
- The patient agrees not to change dosage/frequency of medications without written approval of physician or nurse clinician
- The patient agrees to make an appointment that will return him to the clinic before running out of medications and to keep all scheduled appointments
- The patient agrees to random drug screens by blood or urine
- The patient agrees to use only one pharmacy for your pain medication prescriptions and to make available to this office records from your pharmacy for the purpose of verifying compliance with this contract
- If necessary, the patient agrees to come in to the clinic every 30 days for one month supply of narcotic/controlled substance medications, and understands that NO REFILL will be given if appointment is not kept
- If, under emergency circumstances, you have medication prescribed by another source, you must notify this clinic in writing with in (7) days
- You must participate in all phases of the physician's recommended treatment plan, which may include psychological counseling, physical therapy, diet therapy, and other therapy's as indicated
- You have been advised of specific problems and/or side effects that may occur with the long term use of narcotic medication. You agree to notify Dr. Kropac of any of the problems that you have been advised to be aware of, should such problems occur
- The patient agrees to be called in to clinic for random medication counts. To insure that narcotic/controlled substances are being taken as prescribed
- Failure to provide a valid phone number will result in dismissal from Dr. Kropac's care
The patient has been informed of and agrees to abide by the following clinic rules:
Obtain narcotics and controlled substances from this office only. (This includes family doctor and ER)
Loaning, borrowing, or selling narcotics/controlled substances and this and this office assits the police in prosecutions of individuals who participate in such activities.
From the time the prescription is written the patient is responsible for the medication until the next appointment. LOST or STOLEN PRESCRIPTIONS/MEDICATIONS WILL NOT BE REPLACED BY DR. KROPAC.
I hereby authorize this clinic to furnish any local, state, or federal law enforcement agency any information obtained pursuant to my treatment which is deemed by this clinic to evidence criminal drug activity by me in connection with medicines prescribed to me as a part of said treatment.
I have read the above document, have had any questions answered and agree to the conditions. I understand that if I fail to comply with any of the provisions outlined I may be dismissed from Dr. Kropac's care.