I UNDERSTAND AND AGREE TO THE FOLLOWING Sample Clauses

I UNDERSTAND AND AGREE TO THE FOLLOWING. That this pain management agreement relates to my use of any and all medication(s) (i.e., opioids, also called ‘narcotics, painkillers’, and other prescription medications, etc.) for chronic pain prescribed by my physician. I understand that there are federal and state laws, regulations and policies regarding the use and prescribing of controlled substance(s). Therefore, medication(s) will only be provided so long as I follow the rules specified in this Agreement. My physician may at any time choose to discontinue the medication(s). Failure to comply with any of the following guidelines and/or conditions may cause discontinuation of medication(s) and/or my discharge from care and treatment. Discharge may be immediate for any criminal behavior: I am aware that all controlled substance prescriptions are now being monitored by the Texas State Board of Pharmacy and that information will be accessed by my physician each time a prescription is written. My progress will be periodically reviewed and, if the medication(s) are not improving my function and quality of life, the medication(s) may be discontinued. I will disclose to my physician all medication(s) that I take at any time, prescribed by any physician. I will use the medication(s) exactly as directed by my physician. I agree not to share, sell or otherwise permit others, including my family and friends, to have access to these medications. I will not allow or assist in the misuse/diversion of my medication; nor will I give or sell them to anyone else. All medication(s) must be obtained at one pharmacy, where possible. Should the need arise to change pharmacies, my physician must be informed. I will use only one pharmacy and I will provide my pharmacist a copy of this agreement. I authorize my physician to release my medical records to my pharmacist as needed. My pain management physician will manage the chronic pain symptoms. All other health related issues must be managed by my primary care physician. I understand that my medication(s) will be refilled on a regular basis. I understand that my prescription(s) and my medication(s) are exactly like money. If either are lost or stolen, they may NOT BE REPLACED. Refill(s) will not be ordered before the scheduled refill date. However, early refill(s) are allowed when I am traveling and I make arrangements in advance of the planned departure date. Otherwise, I will not expect to receive additional medication(s) prior to the time of my next scheduled refill, eve...
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I UNDERSTAND AND AGREE TO THE FOLLOWING. 1. This Controlled Substance Agreement relates to my use of any and all medication(s) to manage my condition as prescribed by my provider.
Sample 1
I UNDERSTAND AND AGREE TO THE FOLLOWING. That this pain management agreement relates to my use of any and all medication(s) (i.e., opioids, also called ‘narcotics, painkillers’, and other prescription medications, etc.) for chronic pain prescribed by my physician. I understand that there are federal and state laws, regulations and policies regarding the use and prescribing of controlled substance(s). Therefore, medication(s) will only be provided so long as I follow the rules specified in this Agreement. My physician may at any time choose to discontinue the medication(s). Failure to comply with any of the following guidelines and/or conditions may cause discontinuation of medication(s) and/or my discharge from care and treatment. Discharge may be immediate for any criminal behavior:  My progress will be periodically reviewed and, if the medication(s) are not improving my quality of life, the medication(s) may be discontinued.  I will disclose to my physician all medication(s) that I take at any time, prescribed by any physician.  I will use the medication(s) exactly as directed by my physician.  I agree not to share, sell or otherwise permit others, including my family and friends, to have access to these medications.  I will not allow or assist in the misuse/diversion of my medication; nor will I give or sell them to anyone else.  All medication(s) must be obtained at one pharmacy, where possible. Should the need arise to change pharmacies, my physician must be informed. I will use only one pharmacy and I will provide my pharmacist a copy of this agreement. I authorize my physician to release my medical records to my pharmacist as needed.
Sample 1

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