Controlled substances are recognized by the Federal Drug Enforcement Agency as having a high potential for abuse, dependence, misuse, and diversion, and can be dangerous in combination with other controlled substances such as opioid pain medications. Controlledsubstances commonly used in psychiatric practice include 1.) Stimulants (such as Ritalin and Adderall) for ADHD and 2.) Benzodiazepines (such as Ativan, Xanax, and Klonopin) for anxiety. For your health and safety, your prescriber maintains vigilance over monitoring your use of these and other controlled substances.

The use and prescribing of controlledsubstances is restricted by state and federal regulations. With the rise in prescription drug abuse, regulatory bodies, insurance companies, and prescribers are increasingly more conservative with their use of these agents.

As a patient of Mid-Atlantic Behavioral Health (MABH), you are being asked to sign this document as receipt and understanding of our controlled substance prescribing policy. This agreement will be maintained in your file throughout the course of your care. For your health and safety, deviation from the policy may result in discontinuation of the prescribed medication, referral to an addiction specialist, or discharge from Mid-Atlantic Behavioral Health practice.

  • Our prescribers use clinical judgment to determine the appropriate type and length of treatment. MABH prescribers actively monitor the Delaware prescription drug database and work closely with pharmacists to monitor the dispensing of these medications. Our prescribers reserve the right to refuse to initiate or continue controlled substances based on information obtained from these and other sources. We will make every attempt to offer suitable alternatives and/or discontinue medications in a medically appropriate manner.
  • If you receive controlledsubstances from our office, you may not receive prescriptions for similar medications from any other office during the same treatment period. If you do, you will not receive any subsequent prescriptions from our office.
  • You must inform your prescriber at each scheduled visit of any new or ongoing controlled substance(s) that you receive from another provider (such as a pain medication).
  • You agree to take the medication at the dose and frequency prescribed. As such, the office will not provide early refills.
  • You will not abuse alcohol or use other medically unauthorized substances or medications while you are a patient. Your signature below signifies agreement to random drug screens at the prescriber’s discretion.
  • Controlledsubstances are typically prescribed on a 30-day basis. For established patients who are stable and adherent to follow-up, certain controlledsubstances may be prescribed for up to 90 days.

I, ______, agree to adhere to the Controlled Substances policy.

(Print Patient Name)

______

Patient Signature Date