Florida Medical Clinic, PA
Controlled Substance Agreement
Between Patient: _____________________________________ and Doctor: Barkat Khan, M.D.
The Florida Legislature has laws governing the prescription of controlled drugs. These drugs include all
narcotics (such as codeine, hydrocodone and oxycodone), sleeping aids, benzodiazepines {such as
valium, Xanax and Ativan), and ADHD medications such as concerta, metadata, Ritalin, and vyvanse).
To comply with these laws, I acknowledge and agree to the following:
1.
Prescriptions for most controlled substance medications can only be written for a 30 day supply.
2.
I agree that only my physician will prescribe controlled substance medication. I will not obtain
or use any controlled substances from a source other than my physician. I will instruct my other
physicians to confer with my physician for any changes or need for additional controlled
substance medication. If it Is discovered that other providers are prescribing medications for me,
my physician reserves the right to discontinue prescribing medications and/or discharge me from
the clinic.
3.
Refills must be written {i.e., they cannot be faxed or phoned in). I will need to come in and pick
up the prescription. All medicine should be filled at the same pharmacy, when possible. The
pharmacy I have selected is:(name/phone)
4.
My physician's office requires a 72 hour notice to refill prescriptions. Prescriptions can only be
refilled during normal business hours. They will NOT be refilled at night or on weekends. I
must provide proof of identity to pick up my prescription for controlled substances.
5.
I must be seen by my doctor every 3 months to continue to get refills.
6.
My physician's office is not responsible for any controlled substance medications that have been
misplaced, lost or stolen. Controlled substances cannot be refilled before the renewal date.
7. Routine blood work and random urine drug screens may be part of my treatment plan. I agree to
have them done on the day my physician requests it.
8.
If I do not follow these policies, my physician will not be able to continue to prescribe
these medications for me.
9.
It is a crime to obtain narcotics under false pretenses. This could include getting medications
from more than one doctor, misrepresenting myself to obtain medications, using them in a
manner other than prescribed or diverting the medications in any other way (selling). If my
physician has reason to believe that I have violated this agreement, the physician has the right to
notify and cooperate with law enforcement. If the responsible legal authorities have questions
concerning my treatment, as might occur, for example, if I were obtaining medications at several
pharmacies,
all confidentiality Is waived, and these authorities may be given full access
to my records.
10.
My physician has the right to discontinue controlled substance medications and discharge me
from care if any of the following occur.
•
I trade, sell, misuse or share medication with others;
•
The clinic discovers I have broken any part of this agreement;
•
I do not go for blood work or urine tests when asked;
•
My blood or urine shows the presence of medications that my physician is not aware
of, the presence of Illegal drugs or does not show medications that I am receiving a
prescription for;
•
I get controlled substances from sources other than Florida Medical Clinic physicians;
•
I exhibit any aggressive behavior toward the physicians or staff;
•
I consistently miss appointments.
I hold Florida Medical Clinic physicians harmless from any liability in the event I am dismissed from the
practice for failure to abide by this agreement. I have read and understand the above policy.
Patient/Guardian Signature Date
Printed Patient's Name DOB
Witness
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signature
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