Re: Could you please share your narcotic pain med contract?

[Guest guest]

www.sdcpms.com/pdf/form_sample_opiate_contract.pdfYou could try this one I have it as a template into the note of the emr as a body of text  right? Patient agrees to..... and I name the elements etc

 You can google most of this stuff Helen Google knows everything. I do not ask for a  signature   Never had a  problem when they break it they d on ot argue Occasionally someone gets a second chance they really  just changed phamracies or did soemthing  that  looks egregious but it was innocent.

 maybe that helps?Jean

 

Morning everyone,Could any of you please share your narcotic pain med contract? After the patient signs it and we scan it to the EMR, would you still keep the original copy of the contract?Thank you very much.

Helen

--      MD          ph    fax

[Guest guest]

ooh  link  no work ! here it is as PDF or  google    pain contract

www.sdcpms.com/pdf/form_sample_opiate_contract.pdf

You could try this one I have it as a template into the note of the emr as a body of text  right? Patient agrees to..... and I name the elements etc

 You can google most of this stuff Helen Google knows everything. I do not ask for a  signature   Never had a  problem when they break it they d on ot argue Occasionally someone gets a second chance they really  just changed phamracies or did soemthing  that  looks egregious but it was innocent.

 maybe that helps?Jean

 

Morning everyone,Could any of you please share your narcotic pain med contract? After the patient signs it and we scan it to the EMR, would you still keep the original copy of the contract?Thank you very much.

Helen

--      MD          ph    fax

--      MD          ph    fax

1 of 1 File(s)

form_sample_opiate_contract-1.pdf

[Guest guest]

Here are my documents:Dr. Ballester's Narcotic Policy

Controlled

medications are narcotic pain relievers, medications to relieve anxiety, medications to treat attention deficit disorder, androgens (male hormones), tramadol (Ultram) or carisoprodol (Soma) that are regulated by the State of Ohio and the Federal Government.

There

are several serious side effects, constipation, excessive drowsiness, changes in mood, abuse, misuse and many other side effects and issues.

In

Ohio, and eventually the rest of the States, narcotic prescriptions are

reported in a computer record showing date of dispensing, location of pharmacy, method of payment, what medication, strength, number of pills or capsules and prescriber (Doctor, Dentist, Advance Practice Nurse or Podiatrist) and other details. 

I

am registered to access the Ohio records and will get the reports when a

new patient comes to the office and at any time that I need to clarify the prescription history for controlled substances for an established patient. Law enforcement officials and the Medical and Pharmacy Boards of Ohio can also access these records.

Controlled

substances have caused personal, family, society suffering, severe injuries and death due to adverse reactions, abuse and trafficking. Because of these patient and public safety concerns, my prescription history and medical records of any patient can be examined at any time by the State of Ohio and the Federal Government.

When

I prescribe a medication to a patient and it is used as directed in the

prescription, the chemical or its metabolites should be present in the blood, saliva or the urine of the patient. The medical tests will also reveal the presence of other medications, alcohol or street drugs.

Interpretation of the test results:

True positive results: the prescribed medication is used as ordered and is detected.

True

negative: the prescribed medication is not being used and is not present in the tests, the patient does not need a prescription.

False positive: the test is positive but result is incorrect, the patient is not using the medication.

False

positives can occur frequently in the quick office screen, any positive

result that the patient feels is incorrect will be repeated in the lab using a different method. The lab test will take longer to process, it may take a week or longer to get the reports. The laboratory test is definitely more accurate because the instruments are more sensitive and various metabolites of the medication can be identified. If the laboratory test shows the medication and no metabolites it could indicate that the medication was added to the urine specimen and the patient is not using the prescribed medication.

False negative: the test is negative but the result is incorrect, the patient is using the medication.

A

test may not be sensitive enough to detect small amounts; this can happen with saliva or blood, extremely unlikely with urine specimens.  A

urine specimen could be adulterated (changed by adding water or other chemicals) affecting the result. The laboratory can detect whether the urine has been tampered with or the urine specimen does not belong to the patient being tested (hormones can be tested in the urine that identify male or female patients, other prescribed medications should be

present in the urine).

Consequences of abnormal drug tests:

If

the patient is on buprenorphine therapy, that should be the only prescription or controlled substance present in the urine. If the patient has suffered a relapse and admits to it, the " 3 Strikes Rule " will

apply. After 3 relapses the patient will be dismissed from the practice. If there is no buprenorphine or its metabolites (residues) in the urine, it means the patient is not using the medication and does not need any more prescriptions.

If

the patient is on opioid therapy, only the prescribed opioids should be

present in the urine. If the patient has used other opioids or controlled substance and admits to it, the  " 3 Strikes Rule "  will

apply. After 3 infractions the patient will be dismissed from the practice. If there are no opioid or metabolites (residues) in the urine,

it means the patient is not using the medication and does not need anymore prescriptions.

Only under super-extraordinary circumstances, exceptions or fourth chances could be considered.

If

a patient intentionally tampers with the specimen cup or the urine specimen, this will result in immediate dismissal from the practice without any second chance or reconsideration.

If

a prescription is forged or changed by a patient, this will result in an immediate dismissal from the practice and the incident may be reported to the police and the DEA for criminal prosecution.

Narcotic (Pain Medication) and Anxiety (Nerves) Medication Contract

I am using narcotic pain medications to relieve pain, so I can work or have some quality of life.

I

understand that there are side effects, adverse reactions and dependence on narcotics and sedatives, I will let Dr. Ballester know if I

am having any side effects or adverse reactions.

I am not using narcotic medications to get “High”. I am not sharing or selling my pain medications.

I am not

getting any prescriptions for narcotics or sedatives from any other doctors. If I need or use narcotics from other doctors, I will not get any more prescriptions from Dr. Ballester.

I am not using illegal or “street” drugs, I am not abusing over the counter medications.

If I have an “addiction” problem, I will let Dr. Ballester know to get treatment.

If I lose my medications, I will not ask for a refill.

I will keep my medications in a secure, locked location, if my medications are stolen, I will file a report with the Police and will press charges before asking for a replacement.

I

agree to random urine or blood tests that check for prescription and non-prescription medications or “street” drugs in my body, I will pay for these tests if they are not covered by my insurance. If the test shows that the narcotic is not present (negative test), Dr. Ballester will not prescribe anymore the narcotic. If the test shows the presence of drugs or mind altering chemicals without medical applications, the Doctor-Patient relationship will end immediately.

I

waive any privacy right with regard to communications with Pharmacists,

Doctors, Hospitals, Police, Detectives, Drug Enforcement Agency, State of Ohio Board of Pharmacy.

I understand that Dr. Ballester will

check my prescription history in Ohio, if the report from Ohio or any other State shows that I have filled prescriptions for narcotics from other doctors while this contract is in effect, the Doctor-Patient relationship will end immediately.

I

will schedule follow-up appointments before I run out of medications, I

will not call after hours or during week-ends or Holidays to get refills. If I plan to travel, I will make an appointment to get refills before my trip.

Dr. Pedro A. Ballester has explained the risks and answered all my questions regarding narcotic therapy.

________________________________________ ___________

Patient                                                                       Date

I ask the patient to initial every sentence of the contractFeel free to copy and edit.Corrections or additions are welcomed.Pedro Ballester, M.D.Warren, OH

[Guest guest]

I admire what you're trying to do but perhaps it is a bit much. I stopped reading after a few long paragraphs. Seems doubtful patients would read it all or understand it fully. My two cents.Sent from my iPhone

Here are my documents:Dr. Ballester's Narcotic Policy

Controlled

medications are narcotic pain relievers, medications to relieve anxiety, medications to treat attention deficit disorder, androgens (male hormones), tramadol (Ultram) or carisoprodol (Soma) that are regulated by the State of Ohio and the Federal Government.

There

are several serious side effects, constipation, excessive drowsiness, changes in mood, abuse, misuse and many other side effects and issues.

In

Ohio, and eventually the rest of the States, narcotic prescriptions are

reported in a computer record showing date of dispensing, location of pharmacy, method of payment, what medication, strength, number of pills or capsules and prescriber (Doctor, Dentist, Advance Practice Nurse or Podiatrist) and other details.

I

am registered to access the Ohio records and will get the reports when a

new patient comes to the office and at any time that I need to clarify the prescription history for controlled substances for an established patient. Law enforcement officials and the Medical and Pharmacy Boards of Ohio can also access these records.

Controlled

substances have caused personal, family, society suffering, severe injuries and death due to adverse reactions, abuse and trafficking. Because of these patient and public safety concerns, my prescription history and medical records of any patient can be examined at any time by the State of Ohio and the Federal Government.

When

I prescribe a medication to a patient and it is used as directed in the

prescription, the chemical or its metabolites should be present in the blood, saliva or the urine of the patient. The medical tests will also reveal the presence of other medications, alcohol or street drugs.

Interpretation of the test results:

True positive results: the prescribed medication is used as ordered and is detected.

True

negative: the prescribed medication is not being used and is not present in the tests, the patient does not need a prescription.

False positive: the test is positive but result is incorrect, the patient is not using the medication.

False

positives can occur frequently in the quick office screen, any positive

result that the patient feels is incorrect will be repeated in the lab using a different method. The lab test will take longer to process, it may take a week or longer to get the reports. The laboratory test is definitely more accurate because the instruments are more sensitive and various metabolites of the medication can be identified. If the laboratory test shows the medication and no metabolites it could indicate that the medication was added to the urine specimen and the patient is not using the prescribed medication.

False negative: the test is negative but the result is incorrect, the patient is using the medication.

A

test may not be sensitive enough to detect small amounts; this can happen with saliva or blood, extremely unlikely with urine specimens. A

urine specimen could be adulterated (changed by adding water or other chemicals) affecting the result. The laboratory can detect whether the urine has been tampered with or the urine specimen does not belong to the patient being tested (hormones can be tested in the urine that identify male or female patients, other prescribed medications should be

present in the urine).

Consequences of abnormal drug tests:

If

the patient is on buprenorphine therapy, that should be the only prescription or controlled substance present in the urine. If the patient has suffered a relapse and admits to it, the "3 Strikes Rule" will

apply. After 3 relapses the patient will be dismissed from the practice. If there is no buprenorphine or its metabolites (residues) in the urine, it means the patient is not using the medication and does not need any more prescriptions.

If

the patient is on opioid therapy, only the prescribed opioids should be

present in the urine. If the patient has used other opioids or controlled substance and admits to it, the "3 Strikes Rule" will

apply. After 3 infractions the patient will be dismissed from the practice. If there are no opioid or metabolites (residues) in the urine,

it means the patient is not using the medication and does not need anymore prescriptions.

Only under super-extraordinary circumstances, exceptions or fourth chances could be considered.

If

a patient intentionally tampers with the specimen cup or the urine specimen, this will result in immediate dismissal from the practice without any second chance or reconsideration.

If

a prescription is forged or changed by a patient, this will result in an immediate dismissal from the practice and the incident may be reported to the police and the DEA for criminal prosecution.

Narcotic (Pain Medication) and Anxiety (Nerves) Medication Contract

I am using narcotic pain medications to relieve pain, so I can work or have some quality of life.

I

understand that there are side effects, adverse reactions and dependence on narcotics and sedatives, I will let Dr. Ballester know if I

am having any side effects or adverse reactions.

I am not using narcotic medications to get “Highâ€. I am not sharing or selling my pain medications.

I am not

getting any prescriptions for narcotics or sedatives from any other doctors. If I need or use narcotics from other doctors, I will not get any more prescriptions from Dr. Ballester.

I am not using illegal or “street†drugs, I am not abusing over the counter medications.

If I have an “addiction†problem, I will let Dr. Ballester know to get treatment.

If I lose my medications, I will not ask for a refill.

I will keep my medications in a secure, locked location, if my medications are stolen, I will file a report with the Police and will press charges before asking for a replacement.

I

agree to random urine or blood tests that check for prescription and non-prescription medications or “street†drugs in my body, I will pay for these tests if they are not covered by my insurance. If the test shows that the narcotic is not present (negative test), Dr. Ballester will not prescribe anymore the narcotic. If the test shows the presence of drugs or mind altering chemicals without medical applications, the Doctor-Patient relationship will end immediately.

I

waive any privacy right with regard to communications with Pharmacists,

Doctors, Hospitals, Police, Detectives, Drug Enforcement Agency, State of Ohio Board of Pharmacy.

I understand that Dr. Ballester will

check my prescription history in Ohio, if the report from Ohio or any other State shows that I have filled prescriptions for narcotics from other doctors while this contract is in effect, the Doctor-Patient relationship will end immediately.

I

will schedule follow-up appointments before I run out of medications, I

will not call after hours or during week-ends or Holidays to get refills. If I plan to travel, I will make an appointment to get refills before my trip.

Dr. Pedro A. Ballester has explained the risks and answered all my questions regarding narcotic therapy.

________________________________________ ___________

Patient Date

I ask the patient to initial every sentence of the contractFeel free to copy and edit.Corrections or additions are welcomed.Pedro Ballester, M.D.Warren, OH

[Guest guest]

The contract fits in one page, the long policy is handed for the patient to read at their convenience.Maybe somebody with word skills better than mine can abbreviate the long document and share it with all of us.

Pedro Ballester, M.D.Warren, OH

[Guest guest]

Here's my controlled substances agreement.PS- Soma should never be prescribed. Dangerous medication without any appropriate indication.There is always a better, safer choice. Machata

1 of 1 File(s)

Controlled SUbstance Agreement1.doc