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Rev. July 2019Opioid/Benzodiazepine: Treatment Agreement Date___ Patient: ___ Prescriber:___ Pharmacy:___ 1. I WILL take my opioid/benzodiazepine medication as prescribed. (Usually the medication
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How to fill out benzodiazepine management agreement
How to fill out benzodiazepine management agreement
01
Begin by discussing the purpose of the benzodiazepine management agreement with the patient.
02
Clearly explain the terms and conditions of the agreement, including the expectations for medication use and monitoring.
03
Have the patient review and sign the agreement to indicate their understanding and agreement to comply with the terms.
04
Make a copy of the signed agreement for both the patient and the healthcare provider's records.
05
Schedule regular follow-up appointments to review the effectiveness of the treatment plan and adjust as necessary.
Who needs benzodiazepine management agreement?
01
Patients who are prescribed benzodiazepines for the treatment of anxiety, insomnia, or seizure disorders may need to sign a benzodiazepine management agreement.
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What is benzodiazepine management agreement?
Benzodiazepine management agreement is a contract between a patient and healthcare provider for the safe prescribing and management of benzodiazepine medications.
Who is required to file benzodiazepine management agreement?
Patients who are prescribed benzodiazepine medications and their healthcare providers are required to file the agreement.
How to fill out benzodiazepine management agreement?
The agreement should be filled out by both the patient and healthcare provider, detailing the terms of the benzodiazepine treatment plan.
What is the purpose of benzodiazepine management agreement?
The purpose of the agreement is to ensure the safe and responsible use of benzodiazepine medications.
What information must be reported on benzodiazepine management agreement?
The agreement must include details of the patient's medical history, current medications, dosage instructions, and monitoring plan.
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