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PATIENT LABEL Controlled Substance Agreement Well Span Health Patient Name: DOB: Active Controlled Drug List: These drugs are controlled by special state and federal laws and include opioid (narcotic)
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How to fill out controlled substance agreement
How to fill out controlled substance agreement
01
To fill out a controlled substance agreement, follow these steps:
02
Obtain a copy of the controlled substance agreement form from your healthcare provider.
03
Read the agreement carefully and make sure you understand all the terms and conditions.
04
Gather all the necessary information, including your personal details, healthcare provider's information, and prescription details.
05
Fill in the required fields on the form, such as your name, address, date of birth, and contact information.
06
Provide information about your healthcare provider, including their name, address, and contact details.
07
Fill in the details of the controlled substance prescription, such as the medication name, dosage, and frequency.
08
Review the completed form for any errors or missing information.
09
Sign and date the agreement to signify your consent and understanding of the terms.
10
Return the signed agreement to your healthcare provider or follow their instructions for submission.
11
Keep a copy of the agreement for your records.
Who needs controlled substance agreement?
01
A controlled substance agreement is typically required for individuals who are prescribed controlled substances.
02
This agreement is necessary to ensure that the patient understands the risks and responsibilities associated with the use of these medications.
03
It may be required for individuals with chronic pain, psychiatric conditions, or other medical conditions that require the use of controlled substances.
04
The specific criteria for needing a controlled substance agreement may vary depending on local regulations and healthcare provider policies.
05
It is best to consult with your healthcare provider to determine if you need to fill out a controlled substance agreement.
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