Controlled Substance Consent Form

The state of Louisiana and many surrounding states have started a controlled substance database. Whenever you refill a prescription for a controlled substance, the system records the date the prescription was sent, the date the prescription was filled, the name of the medication, the dosage, the quantity, the prescriber, and the method of payment. Health Care Providers (HCP) and pharmacies are required to check the database, if there are irregularities in your database; your HCP may not be able to prescribe controlled substances for you. Controlled substances have a risk for abuse or misuse and include, but are not limited to, narcotic pain medicines, stimulants, benzodiazepines, and barbiturates.

In an effort to prevent these problems and comply with state and federal regulations, I, a patient of Nicole Johnson, PMHNP, understand that it is necessary to observes strict rules pertaining to the use of controlled substances.

I AGREE & UNDERSTAND THAT:

1. I will not request early refills. If I need an early refill due to loss, damage, or theft of my medication, I may be required to provide a filed police report before getting additional prescriptions. If I request an early refill secondary to lost, damaged, or stolen prescriptions twice within a year, I might be discharged from the practice.
2. I will attend an appointment at least every two months to receive refills for my controlled substances. In rare cases when I cannot keep an appointment due to a valid reason, the HCP will provide a one-week supply (without refills) of the controlled substance(s) to allow time to reschedule my appointment.
3. I will take my medication exactly as prescribed. I will not break, crush, chew, inject, snort, or alter my medication in any way. The prescriber must approve any change in dosage. If I think I need to change the dosage or type of controlled substance that I am taking, I will schedule an appointment rather than try to make changes by telephone/ messaging or adjusting the dose myself. I will not receive prescriptions for controlled substances through other HCPs without informing Nicole Johnson, PMHNP.
4. I will not allow others to have, use, sell, or otherwise have access to my prescribed controlled substances. I will not attempt to obtain a controlled substance under false pretenses or allowing others to fill prescriptions under my name. I will not change or tamper with any written prescriptions.
5. I will undergo urine toxicology screenings every six months. I will also cooperate with any random requested urine or serum toxicology screenings, as well as random pill counts of the controlled substance upon request. Failure to comply or the presence of unauthorized and/or illegal substances in urine or serum toxicology screenings may prompt referral for assessment for substance use disorder treatment or discharge from the practice.
6. Controlled substances should not be stopped abruptly, as withdrawal syndromes may develop. Controlled substances have some degree of risk of developing an addictive disorder or suffering a relapse of a prior addiction. I will keep controlled substances secured and out of reach from children, as their accidental ingestion could be lethal.