Here's my CSA. I lost the formatting with the cut & paste. Note that I try to make as much of it as possible the patient's responsibility, e.g., pregnancy, driving, making sure meds aren't stolen.
The Center for Pain Relief Controlled Substances Agreement
Prescribing narcotics and other controlled substances requires very high vigilance and strict adherence to guidelines. Please read and sign the following Agreement. This is not a condition for treatment of your pain. However, if you do not sign it you will not receive prescriptions for controlled
substances from this practice.
I agree to participate in a pain management program with The Center for Pain Relief (hereafter CPR). I will be provided with controlled substances while actively participating in this program only if I adhere to the following rules:
1. Compliance. I will use controlled substances only as directed by the CPR medical staff and will refrain from using any illicit drugs while on these medications. I agree to submit to random blood and urine tests to detect compliance with this contract at any time should CPR medical staff request it.
2. No early refills. I understand that I may not increase my dose without prior approval by CPR. Approval will not be given after the fact. I understand that the safe-keeping of my medications is my sole responsibility and that I will not receive replacements for lost or stolen medications. I understand that if I take more than the prescribed amount of medication, or my medication is lost or stolen, I run the risk of having withdrawal symptoms because my medication will NOT be refilled early.
3. Change in pain. Any changes in my pain pattern that cause me to request an increase in pain medication must be addressed at an office visit for evaluation.
4. Refill requests. Refills will be done at 30 day intervals. I understand that prescription and medication refill requests are only accepted 9:00am - 5:00pm, Monday through Thursday and 9:00am 3:00pm on Friday. NO MEDICATION OR REFILL REQUESTS WILL BE TAKEN DURING NIGHTS, WEEKENDS, OR HOLIDAYS. I also understand that it is my responsibility to anticipate the need for refills and make refill requests in a timely manner, allowing two (2) to four (4) business days, as outlined in the document Medication Refill Procedures. I will not make repeated calls to the office for prescriptions, nor will I subject the office staff to rude or abusive behavior if prescriptions are not filled as quickly as I would like.
5. Delivery costs. The Center for Pain Relief does NOT mail out prescriptions. I understand that only Dr. Gorback can reverse this policy and will do so rarely and under only the most extreme circumstances. If prescriptions are mailed to me, I agree to pay for postage, including the cost of certified mail and other special delivery conditions, such as overnight delivery. I also agree to pay an administrative fee for shipping and handling. I understand that this may not be covered by my insurance and that I am expected to pay for these services myself.
6. Diversion. I understand that it is illegal to share my prescription drugs or sell my prescription drugs to other people, and agree to take strict precautions to prevent unauthorized access to my medications.
7. Exclusive provider of narcotic substances. I will receive controlled substances only from the CPR medical staff. I agree to inform my other doctors that I am receiving these medications and request that they consult with CPR before prescribing any medications that might alter mood or consciousness.
8. Detoxification. I agree to participate in a detoxification program if prescribed by a CPR physician.
9. Side effects. I understand that controlled substances may cause a variety of side effects, including, but not limited to: nausea, vomiting, constipation, dry mouth, difficulty with urination, weight changes, suppressed immune system, altered hormone levels (thyroid, sexual hormones), itching, allergic reactions, fluid and blood chemistry imbalances, and altered sexual function. I understand that taken improperly, controlled substances may cause excess sedation, depressed breathing and even death, especially if combined with alcohol or other mood- or consciousness-altering substances. I understand that these medications may alter my ability to drive a car or other heavy machinery and I will comply with all state and federal laws regarding such activities while using these medications.
10. Tolerance, Dependence and Addiction. I understand that controlled substances may cause physical dependence and that sudden withdrawal may cause symptoms such as abdominal and muscle cramps, sweats, chills, nausea and vomiting. In rare cases it may cause death. I understand that these drugs must be withdrawn slowly. I understand that I may become tolerant to these drugs and require increasing doses for the same amount of pain relief. I understand that there is a small but real chance that I may become psychologically addicted to these medications.
11. Pregnancy. I understand that controlled substances may have adverse effects on the fetus, and that there is a strong likelihood that any baby born to a woman taking controlled substances will probably be physically dependent and could suffer withdrawal symptoms. FOR FEMALE PATIENTS: I agree to notify CPR if I become, or intend to become, pregnant. If I have not been sterilized or am not postmenopausal, I agree to take reasonable and prudent precautions to ensure that I will not become pregnant while taking these medications.
12. Relocation. I understand that Dr. Gorback treats patients who live in the Houston area only. Determination of the geographic coverage area is at the sole discretion of Dr. Gorback. If I relocate outside of the Houston Area, I agree to withdraw as a patient at CPR and locate another physician to take over my treatment within thirty (30) days of relocating. I understand that finding another physician is solely my responsibility.
13. Termination. Termination of narcotic drug therapy may be instituted for any violation of this agreement or at the clinical discretion of the CPR staff. I agree to obtain an alternate source of medical care and controlled substances within 30 days of notification of violation of this agreement or enroll in a detoxification program within this time frame. I will not hold any member of the CPR staff liable for any sequelae of discontinuance of controlled substances provided 30 days of notification of termination is provided. I will not seek controlled substances from the CPR staff if I decide to discontinue participation in the pain treatment program.
I have read and understand all of the above terms. I have had the opportunity to ask questions about these terms and all of my questions have been answered to my satisfaction. I agree to abide by the terms and provisions of this agreement and understand that failure to do so will lead to termination of treatment.
Printed Name ________________________________________________Date__________________
Patients Signature__________________________________________________________________
