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CONTROLLED SUBSTANCE AGREEMENTNORTH DAKOTA DEPARTMENT OF HUMAN SERVICES HUMAN SERVICE CENTERSClear Fieldsman 736 (112016)Patient NameClient ID NumberWhile there are numerous treatments for your condition,
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How to fill out controlled substance agreement

01
Start by reading and understanding the controlled substance agreement form.
02
Provide your personal information such as name, address, date of birth, and contact details.
03
Indicate the specific controlled substances that you are being prescribed or have access to.
04
Acknowledge the potential risks and responsibilities associated with the use of controlled substances.
05
Familiarize yourself with the terms and conditions of the agreement, including the requirement for regular check-ups and medication monitoring.
06
Ensure that you understand the consequences of non-compliance with the agreement.
07
Sign and date the agreement, demonstrating your willingness to abide by the terms outlined.
08
Make a copy of the completed agreement for your records.
09
Submit the filled-out controlled substance agreement to the relevant healthcare provider or pharmacist.

Who needs controlled substance agreement?

01
Individuals who have been prescribed controlled substances by a healthcare professional.
02
Patients who require ongoing access to and use of controlled substances for medical purposes.
03
People with chronic pain conditions or other medical conditions that necessitate the use of controlled substances.
04
Patients receiving certain medications or treatment plans that are regulated by controlled substance laws.
05
Individuals who are part of substance abuse treatment programs and may be required to sign a controlled substance agreement as part of their recovery process.
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Controlled substance agreement is a legal document that outlines the terms and conditions for the use of controlled substances.
Any individual or entity that is authorized to handle or distribute controlled substances is required to file a controlled substance agreement.
Controlled substance agreement can be filled out by providing all the required information, such as the name and address of the individual or entity, the types of controlled substances being handled, and the quantity of controlled substances being distributed.
The purpose of controlled substance agreement is to ensure that controlled substances are being handled and distributed in compliance with laws and regulations.
The information that must be reported on controlled substance agreement includes the name and address of the individual or entity, the types and quantities of controlled substances being handled, and any other relevant details.
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