Online Prescription Management Agreement for ADHD Medications

Online Prescription Management Agreement for ADHD Medication

Patient Name:*
First Last
Date of Birth:
MM slash DD slash YYYY
MRN:
The long-term use of ADHD medication is controversial, because of uncertainty regarding the extent to which they provide long-term benefits. Because these medications have potential for abuse or diversion, strict accountability is necessary when use is prolonged. For this reason, the following policies are agreed to by you, the patient.
Consent:*
The agreement below has been explained to me and I agree to its terms.
1. You are expected to inform our office of any new medications or medical conditions, and of any adverse effects you experience from any of the medications you take.
2. The prescribing provider has permission to discuss all diagnostic and treatment details, including a copy of this agreement, with dispensing pharmacists or other professionals who provider your health care for purposes of maintaining accountability.

3. You may not share, sell, or otherwise permit others to have access to these medications.

4. Prescriptions and bottles of these medications may be sought by individuals with chemical dependency and should be closely safeguarded.

5. Medications may not be replaced if they are lost, get wet, are destroyed, etc. If your medication has been stolen, and you complete a police report, an exception will be made.

6. I understand that refills of my prescription will be made only at the time of an office visit or during regular office hours. No refills will be available during evenings or on weekends.

7. Early refills will only be given if provider or patient will be out of town when a refill is due.

8. If the responsible legal authorities have questions concerning your treatment, all confidentiality is waived and these authorities may be given full access to our records of controlled substances to administration.

9. It is understood that failure to adhere to these policies may result in cessation of therapy. Should this happen, my provider will taper off the medicine over a period of several days to avoid withdrawal symptoms. Also, a drug-dependence treatment program may be recommended.

10. The risks and potential benefits of these therapies are explained elsewhere, and you acknowledge that you have received such explanation.

11. Due to restrictions and regulations enforced by the Mississippi State Board of Medical Licensure, appointments may be required every 3 months for treatment to continue and I may be required to have periodic random urine and/or blood drug testing.
12. You affirm that you have full right and power to sign and be bound by this agreement.

13. I will use one pharmacy to obtain prescriptions.

14. I will not use illicit drugs while taking this medication (such as cocaine, marijuana, etc.). I understand if I do, it will lead to discontinuation of prescribed mediation and/or termination of provider/patient relationship.

15. I will not attempt to obtain any controlled medications including opioids, controlled stimulants, or anti-anxiety medications from any other provider.

16. I will not use my medication at a rate greater than the prescribed rate. I understand that using my medication at a rate greater than the prescribed rate will result in my being without medication for a period of time.

17. I will bring all unused medication to every office visit.
Patient's Signature:*
Provider's Signature (Please leave this area blank. Your provider will sign this area.):