PSYCHIATRIC MEDICATION TERMS AND CONDITIONS OF AGREEMENT, CODEOF CONDUCT, AND DRUG TEST AUTHORIZATION

• I am able to read, write, and understand English and have read this Agreement in its entirety, or have had this Agreement translated for me in my native language and have read the translated version in its entirety;
• I have been given ample time to address this Agreement with Dr. Afrina and to ask her questions about its terms; and
• I fully understand what is expected of me under this Agreement.

B. Terms and Conditions of Treatment

1. I understand that while I am a patient of DCP, I may receive treatment from Dr. Afrina, from another DCP psychiatrist, or from an advanced practitioner who may be a Physician Assistant or an Advanced Practice Nurse. I further understand that for the purposes of this Agreement, Dr. Afrina, other DCP physicians, and the advanced practitioners shall be referred to collectively as "the Treatment Team."
2. I understand that I have the right to comprehensive treatment of my mental health condition(s) I further understand that there are different ways to treat mental health condition(s), such as through psychotherapy, group counseling, and/or the use of medications, some of which may be controlled substances (that is, medications that are subject to stringent federal and/or state law regulation).
3. I understand that that the primary goal of my treatment plan is to improve my ability to carry out my daily activities.

PSYCHIATRIC MEDICATION AGREEMENT

 

4. I understand that the Treatment Team may, in its sole discretion, refer me to one or more specialist physicians or other healthcare providers for treatment of other medical conditions that may be affecting my mental health. These specialist physicians or other healthcare providers may include, but are not limited to, addictionologists, pain management specialists, and/or occupational, physical, or relaxation therapists. I agree to consult with any specialist physician or other healthcare provider to whom I may be referred by the Treatment Team, and if the specialist physician or healthcare provider is satisfactory to me, and to comply with all treatment recommendations made by that person. If a specialist physician or other healthcare provider is unsatisfactory to me for any reason, I agree to inform the Treatment Team of this fact, to request a referral to another physician or healthcare provider practicing in the same specialty area, to consult with that specialist physician or healthcare provider, and to comply with all treatment recommendations made by that person.
5. I understand that only Dr. Afrina and other DCP psychiatrists (collectively, "DCP Psychiatrists") will be prescribing controlled substances pursuant to this Agreement, but that other members of the Treatment Team will play a role in my care as well and may prescribe other types of medications used to treat mental health conditions. I agree to use any and all medications prescribed by the DCP Psychiatrists and/or other members of the Treatment Team in accordance with the terms and conditions of this Agreement and as prescribed.
6. I UNDERSTAND THAT IF I DO NOT COMPLY WITH THE TERMS AND CONDITIONS OF THIS AGREEMENT, AND DO NOT TAKE THE PRESCRIPTION(S) IN THE MANNER PRESCRIBED, OR TAKE MEDICATIONS THAT THE TREATMENT TEAM IS UNAWARE OF AND HAS NOT PRESCRIBED, THEN THE TREATMENT TEAM MAY REDUCE, CHANGE OR EVEN TERMINATE MY PRESCRIPTIONS AND MAY ALSO DISCHARGE ME FROM THE CARE OF DCP OR RECOMMEND TREATMENT WITH A DIFFERENT PROVIDER AND THEREAFTER CEASE TREATING ME. IF MEDICATIONS ARE BEING ABUSED OR TAKEN INAPPROPRAITELY WHILE UNDDER THE CARE OF A PROVIDER OTHER THAN DCT, WE WILL NOTIFY THE OTHER PRESCRIBING PROVIDER OF THIS POTENTIAL MISCONDUCT.
   
   I ALSO AGREE TO KEEP THE TREATMENT TEAM UPDATED WITH ANY CHANGES IN PRESCRIPTIVE MEDICATION THAT I MAY BE TAKING PRESCRIBED BY OTHER HEALTH CARE PROVIDERS. I FURTHER AGREE THAT I WILL ALSO KEEP THE TREATMENT TEAM FULLY ADVISED OF ANY OVER THE COUNTER MEDICINES, HERBS, SUPPLEMENTS, VITAMINS OR OTHER PRODUCTS THAT I MAY BE TAKING AT ANY TIME DURING MY CARE BY DCT. FINALLY, I AGREE THAT DURING THE PERIOD OF MY CARE AND TREATMENT AT DCT. FINALLY, I AGREE THAT I WILL NOT

PSYCHIATRIC MEDICATION AGREEMENT

UTILIZE ANY ILLEGAL OR STREET DRUGS OF ANY KIND, AND IF I DO SO, SUCH ACTION IS GROUNDS FOR IMMEDIATE TERMINATION AS A PATIENT AT DCT. I ALSO AGREE THAT THE TEAM AT DCT MAT ORDER ME TO TAKE A DRUG TEST WHICH MAY INCLUDE URINE, BLOOD OR HAIR TESTS, OR ALL THREE, AND REQUIRE THAT SUCH TESTS SHALL BE "OBSERVED TESTS" WITH SUCH FREQUENCY AS DCT DEEMS NECESSARY IN ITS MEDICAL AND PROFESSIONAL DICSCRETION. THE FAILURE TO TAKE ANY DRUG TEST REQUIRED BY DCT MAY BE GROUNDS FOR IMMEDIATE DISCHARGE AS A PATIENT OF DCT.

7. I understand that prescribed medications may not always be effective with every patient. I further understand that my treatment plan may change from time to time, especially if one or more of the medications prescribed for me are or become potentially ineffective or cause side effects that may necessitate a change in medications. I agree to immediately advise the Treatment Team of any side effects of any medications.
8. I understand that there is a risk that I could become physically or psychologically dependent on the medication(s) prescribed for me, which means that I may not be able to control my use of such medication(s), and that the Treatment Team will be looking for signs of dependency, such as running out of medications and seeking early refills. I am entering into this Agreement to minimize the risk that I will become dependent on any medication(s I further understand that if dependency occurs, the medication(s) prescribed for me may be discontinued, reduced, or changed to a different prescription at the sole discretion of the Treatment Team and I may be referred to a drug treatment program or addictionologist for assistance. I agree to participate in any drug treatment program to which I have been referred by DCT.
9. I understand that no refills will be given on any medication prior to my next scheduled appointment date and that if I do not keep my appointment, I will not receive a refill. I further understand that I will not receive a new prescription for lost or stolen medications under any circumstances, even if I have filed a police report.
10. I authorize the Treatment Team to cooperate fully with city, state, or federal law enforcement agencies to investigate any possible misuse, sale, or other diversion of my medications. I agree to waive any right to privacy or confidentiality with respect to this authorization.
11. I recognize how important it is to my general health and well-being to follow all orders and recommendations of the Treatment Team. Consequently, I hereby agree to the following Code of Conduct and terms. I specifically agree to: 

PSYCHIATRIC MEDICATION AGREEMENT

2. be respectful to each member of the Treatment Team, even if I disagree with a decision regarding my treatment plan or the medication(s) prescribed for me;
3. completely and truthfully answer all questions posed by any member of the Treatment Team about my health, medical treatment that I have received in the past or am receiving now, and/or medications that I have taken in the past or am taking now;  
   
   take any and all medications prescribed for me by the Treatment Team as directed, and not change the way in which I have been directed to take any medication(s) (for example, by increasing or decreasing its dosage or by taking it in the morning when it is supposed to be taken at bedtime) without first getting the approval of a member of the Treatment Team to do so;
4. notify a member of the Treatment Team not more than 24 hours after any other physician or healthcare provider prescribes for me any anti-anxiety medication(s), anti-depressant(s), painkiller(s), sleep aid(s), stimulant(s), or any controlled substance;
5. show up for any and all required follow-up visits with the Treatment Team so that my use of medication(s) may be properly monitored;
6. ONLY fill the prescriptions for medication(s) prescribed by the Treatment Team at the pharmacy listed below:

7. make sure that I do not run out of my medication(s) on weekends and holidays, because abrupt discontinuation of such medication(s) may cause severe withdrawal syndrome;
8. not fill or try to fill prescriptions for the same medication(s) at more than one pharmacy or seek multiple prescriptions for the same medicine from different physicians;
9. provide the Treatment Team with a list setting forth any and all medications prescribed for me by any health care provider, along with the prescribed dosage, and update the list every time a medication is discontinued, a new medication is prescribed, or the dosage of any medication is changed;

PSYCHIATRIC MEDICATION AGREEMENT

10. provide the Treatment Team with a list setting forth any and all over-the-counter ("OTC") dietary or herbal supplements, medications, and vitamins that I am taking (including but not limited to anything containing ephedrine, human growth hormone, Kratom, Phenibut, St. John's Wort, or testosterone), whether or not prescribed by a physician, along with the amount consumed daily, and update the list every time I stop taking, start taking, or change the amount of or way in which I take any OTC dietary or herbal supplement, medication, or vitamin;
11. consult with a member of the Treatment Team before taking any new OTC dietary or herbal supplement, medication, or vitamin;
12. not use illegal controlled substances of any kind, including but not limited to cocaine, heroin, marijuana, methamphetamines and/or any street drug of any kind;
13. not use any mind- or mood-altering drugs, hallucinogens, or other substances (even if obtained legally) or alcoholic beverages, unless I have first secured the advance approval of the Treatment Team;
14. submit to toxicology testing of my blood, hair, and/or urine ("toxicology testing"), which may be requested by the Treatment Team at any time;
15. keep my medication(s) safe, secure, and out of the reach of children and pets; and
16. sign a release enabling the Treatment Team to speak to all physicians and all other healthcare providers, including any pharmacists who are treating me or who may be providing prescriptive medications for me for any medical or mental health condition.

C. Termination of Agrrement

1. I understand that the DCP Psychiatrists are under no obligation to prescribe controlled substances for me, and that they reserve the right to refuse to prescribe, to change or to discontinue such medications at any time, in their sole professional judgment.
2. I understand and agree that the DCP Psychiatrists may terminate this Agreement and our doctor-patient relationship if any of the following should occur:

1. without the prior consent of the DCP Psychiatrists, I seek or obtain controlled substances from a source other than the DCP Psychiatrists or another treating physician; I
2. seek or obtain controlled substances from a non-medical source, including a family member or friend;

PSYCHIATRIC MEDICATION AGREEMENT

3. I do not show up for two or more follow-up visits with the Treatment Team and fail to provide a valid excuse for such failure;
4. I cancel two or more follow-up visits with less than 24 hours' notice;
5. I refuse to undergo toxicology texting when asked to do so by a member of the Treatment Team;
6. I am disruptive, threatening, insulting, vulgar or act in an unprofessional manner to the DCP practice and its employes in any way;
7. I am disrespectful to any member of the Treatment Team, the DCP support staff, or other patients;
8. my mental health condition declines to the point where, in the Treatment Team's judgment, continued use of my medication(s) presents a danger to my health, safety, or overall well-being;
9. there is evidence that I am no longer receiving a reasonable therapeutic benefit from my medication(s);
10. the Treatment Team determines that I am no longer a good candidate to continue to use the medication(s) prescribed for me;
11. I develop side effects that the Treatment Team considers to be significant; or 
12. I fail to comply with any term or condition of this Agreement.

 

1. I understand that the DCP Psychiatrists will notify me in writing or by email if this Agreement is terminated for any reason. The termination will be effective 30 days from

PSYCHIATRIC MEDICATION AGREEMENT

the date that I receive this notice from the DCP Psychiatrists unless otherwise stated to be a termination on less than thirty (30) days' notice.

 

D. Approved Alternative Provider

In the event that a member of the Treatment Team is not available to see me at any time, I agree to use only the following providers:

E. Depression/Suicide Aggreement

I acknowledge that persons suffering with mental health conditions may have difficulty coping with their symptoms and/or treatment. I agree that should I have thoughts of suicide or of harming myself or any other person, I will immediately contact a member of the Treatment Team or go to the nearest Emergency Room and report my symptoms. I further agree to seek and follow professional advice, and if I am referred for psychiatric treatment, including but not limited to impatient services, I agree to seek such treatment without delay. In case of any hospitalization, I will request that the Treatment Team be notified of such hospitalization.

F. Legal effect of Signing this Agreement

I acknowledge and agree that I have met with one or more members of my Treatment Team and the foregoing terms and conditions for receiving mental health treatment from DCP, including medications, was reviewed with me in detail. I acknowledge that I was given sufficient time to ask questions and each of my questions was answered fully and to my satisfaction.

I am signing this Agreement knowingly and of my own free will. I have either consulted legal counsel of my choosing about its effects, or have chosen, in my own informed discretion, to voluntarily waive the right to consult such counsel. I have initialed each page of the Agreement indicating my understanding of the contents of such page and intent to comply with the terms and conditions on such page. I acknowledge that I have been provided with a signed copy of the Agreement.

PSYCHIATRIC MEDICATION AGREEMENT

PSYCHIATRIC MEDICATION AGREEMENT