Controlled Substance Contract

Controlled substance medications (stimulants, benzodiazepines, and tranquilizers) can be effective in the treatment of certain mental health disorders.  Controlled substances are highly regulated.  As such, the Behavioral Medical Center – Troy follows a stringent protocol when prescribing these medications.

Please review the following Patient Responsibilities and sign at the bottom to indicate your understanding and agreement of these policies. 

Because my clinician is prescribing controlled substance medications as part of my treatment plan, I agree to the following conditions:

• I will attend appointments at the Behavioral Medical Center – Troy at the frequency deemed appropriate by my clinical team.
• I give permission to the Behavioral Medical Center – Troy to access and review my prescription history at random intervals.
• I will fully disclose all current medications both short-term and long-term to my treatment team, and will notify my prescriber of changes to my medication regimen.
• I am responsible for the medications prescribed to me.  If my prescription is lost, stolen, or misplaced or if I take more than what is prescribed to me, my prescription will not be replaced.
• I give permission for my clinician to discuss my diagnosis and treatment plan with other clinicians providing my medical care.
• I will use one pharmacy for all of my prescriptions.  I will register the name and phone number of the pharmacy with my clinician. Should a change of pharmacy be necessary, I will promptly notify the office.
• Refill requests from pharmacies will not be accepted.
• I agree to undergo random urine, blood or saliva testing per the protocol of the Behavioral Medical Center – Troy.  The presence of illicit drugs, the absence of my prescribed medications, or failure to comply with the screening will be considered a breach of contract and may be grounds for dismissal from the practice.
• I will not request or accept controlled substance medications from any other clinician or individual while I am receiving such medications from the Behavioral Medical Center – Troy.
• I will not give, share, or sell my medications to any other person.

Patient or Parent/Guardian Signature (if the patient is a minor)