PAIN MANAGEMENT AGREEMENT

I understand that in order to receive care for the treatment of pain at A.A. Pain Clinic, Inc., I agree to and will comply with the following:

A. MENTAL HEALTH: A mental health assessment and/or continuing psychological therapy may be required. If I am currently involved in mental health therapy, or if I enter such therapy, I will authorize my mental health practitioner to exchange unrestricted information regarding my condition and treatment with the health care providers of A.A. Pain Clinic, Inc.

B. USE OF MEDICATIONS: I will take all medications as prescribed. I will speak with a provider of A.A. Pain Clinic, Inc. before making any change in either the dose or frequency of my medications. There will be no early refills of pain medications without prior authorization. Narcotic pain medications must all be obtained from the same pharmacy (any exception must be approved by A.A. Pain Clinic, Inc.).

C. SEEKING PRESCRIPTIONS: I will neither seek nor fill prescriptions for any medications related to pain relief from any other health care provider unless authorized by A.A. Pain Clinic, Inc.

D. MEDICAL RECORDS RELEASES: I will inform all of my health care providers that I receive pain management through A.A. Pain Clinic, Inc. and will maintain an unrestricted and current medical records release on file with A.A. Pain Clinic, Inc. TOP

E. DRUG SCREENING: I will participate in drug screening as a part of my treatment plan. I understand that drug screening will be conducted at least every 12 months and may be required more frequently at the discretion of A.A. Pain Clinic, Inc. Screening may include urinalysis, blood testing or pill counts. I agree to pay any and all costs associated with drug testing not covered by my insurance. Refusal to submit to screening at the time specified may result in termination of services.

F. ILLEGAL AND NON-PRESCRIBED DRUG USE: I understand that the use any controlled medication not prescribed by A.A. Pain Clinic, Inc. may result in termination of care. I authorize A.A. Pain Clinic, Inc. to cooperate fully with any city, state or federal law enforcement agency, including this state's Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my pain medicine. I authorize A.A. Pain clinic to provide a copy of this Agreement to my pharmacy. I agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations. I also understand that the use of any illegal substance, including marijuana, will result in termination of care by A.A. Pain Clinic, Inc.

G. LOST OR STOLEN MEDICATIONS: I agree to safeguard all medications prescribed by A.A. Pain Clinic, Inc. and understand that lost or damaged medications will not be replaced.

H. PRESCRIPTIONS WHILE TRAVELING: A.A. Pain Clinic, Inc. may provide prescriptions for up to 90 days when patients are traveling out of state. Patients will have to arrange for shipment of controlled substances by their pharmacy at their own expense. Patients who will be out of state longer than 90 days need to arrange for health care at their travel destinations.

I. DRIVING & OPERATING EQUIPMENT: Many pain medications can cause drowsiness and/or a very relaxed state of mind causing operation of equipment or vehicles to be dangerous. I agree to refrain from driving or operating dangerous equipment for 72 hours after any change in medication dosage and whenever I feel drowsy. TOP

J. MISSED APPOINTMENTS:  Please contact the clinic if you will be 5 to 10 minutes late. If I arrive later than 15min, I will be rescheduled. Three missed appointments per year are grounds for termination from AA Pain Clinic.

K. CANCELLATIONS: As of October 1, 2007; we require a 24 hour notice to cancel or reschedule your appointment. Appointments missed, rescheduled due to tardiness, or rescheduled without a 24 hour notice will result in a $50.00 fee to the patient.

L. TERMINATION:  I will no longer be eligible for care at A.A. Pain Clinic if I am in possession of illicit drugs or substance, trafficking in controlled or illegal substances, intoxicated or convicted for DUI.  If I forge or alter the prescriptions in anyway, sell or share medications, or fail to comply with this contract, I will no longer be eligible for care at A.A. Pain Clinic.

M. TREATMENT OF STAFF: Our clinic has a zero tolerance policy for verbal abuse towards our staff. Swearing, yelling at, or threatening of our staff will result in termination from our clinic.

N. EMERGENCY ROOM VISITS:  I am allowed to receive pain medication in the emergency room, but it is a violation of the A.A. Pain Clinic contract to receive narcotic medication to take home and must be discussed with the on-call doctor prior to receiving medication. A violation includes any prescription and/or samples.

O. SUBOXONE AGREEMENT: Choosing a Suboxone treatment clinic, or taking Suboxone while under the care of an AA Pain Clinic provider, voids your contract with AA Pain Clinic and will result in termination, ending treatment by all providers of AA Pain Clinic. Patients entering AA Pain Clinic after being treated with Suboxone, will discuss with AA Pain Clinic before discontinuing your prescribed narcotics for pain management. You agree to take your prescribed narcotics as directed by your pain specialist at AA Pain Clinic. You agree not to take Suboxone while being treated with narcotics prescribed by AA Pain Clinic, Inc.

Have you ever had any medical or legal problems with alcoholism, drug abuse (including marijuana), addiction or drug trafficking? Yes No. If yes, please explain:

Have you used any illegal drugs (including marijuana) within the past six months? Yes No
If yes, list the drugs you have used and when:

Have you used any prescription drugs for which you did not have a personal prescription within the past six months? Yes No. If yes, please explain:

I UNDERSTAND AND AGREE TO THE CONDITIONS OF CARE DESCRIBED ABOVE AND WILL COMPLY WITH THEM. ALL OF MY QUESTIONS ABOUT THE TERMS OF THIS AGREEMENT HAVE BEEN ANSWERED TO MY SATISFACTION. FAILURE TO COMPLY WITH ANY OF THE TERMS OF THIS AGREEMENT MAY RESULT IN IMMEDIATE TERMINATION OF SERVICE.

Patient Signature and Date |  Practitioner Signature and Date (download contract) TOP