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Call today:  Seymour 812-519-2963

                 Greensburg 812-663-7640

Treatment Agreement

Purpose: Protect your access to controlled substances, and protect our ability ti prescribe to you.

Because these drugs have potential for abuse or diversion, strict accountability is necessary.  For this reason, the following policies are agreed to by you (the patient), as consideration for, and a condition of, the prescribing provider, whose signature appears below, to consider the initial and/or continued prescription of controlled substance to treat your chronic pain.

  • I agree opiods will be prescribed ONLY by this office
  • I agree not to fill a prescription for any pain medication or mind-altering medications prescribed by another provider (dentist, emergency room physician) without first discussing it with Health Centered Spine and Wellness.
  • I understand that I may take medications for pain while an inpatient or as an emergency department patient.  YOU MAY NOT FILL PAIN MEDICATION SCRIPT FROM ANOTHER PROVIDER UNLESS DISCUSSED PRIOR TO AND APPROVED.
  • I will not share, sell, or otherwise permit others to have access to this medication.
  • I will not drink ANY alcoholic beverages while under the care of the prescribing provider.
  • I understand unannounced urine or serum toxicology screens will be requested, and my cooperation is required.  Presence of unauthorized substances or lack of presence of prescribed medication will result in discharge from the practice
  • I may be called for a random pill count and will present with my prescription by the end of the day I am called.  Failure to do so will result in discharge from the practice.
  • I must maintain in my chart a working phone number with voicemail setup at all times.  If we are unable to reach you for pill count, you will be discharged from care.
  • I understand that it is my responsibility to disclose all medications that I am taking so as to assist the provider wit the most appropriate care.
  • I agree to take this medication as prescribed and not to change the amount or frequency of the prescribed medication
  • I understand if I am going to e out of town during the week, I must call the office and notify the staff.  If you are called for a pill count and have not informed us of being out of town prior to our call, and you are unavailable for pill count, you will be discharged.
  • I understand that if my medication is lost, stolen, destroyed, or get wet, ect, medications will not be replaced and you will be discharged for not safe keeping your medication.
  • I agree renewals are contingent on my compliance to the treatment plan: this means keeping all scheduled appointments which may include, but not limited to , diagnostic tests, massage/physical therapy, chiropractic care, and use pf durable medical equipment prescribed.  If more than 3 appointments are cancelled or missed you could be discharged from our practice.
  • I give permission to the prescribing provider to discuss all diagnostic and treatment details with the dispensing pharmacists or other professionals who provide services to me for the purposes of maintaining my accountability.
  • I agree that I will attend all required follow-up visits to monitor this medication and I understand that failure to do so will result in discontinuation of this treatment.  I also agree to participate in other chronic pain treatment modalities recommended by my provider.
  • It should be understood that any medical treatment is initially a trail, and that continued prescriptions is contingent upon evidence of benefit.