Download Pain Contract - Dr. Hoyman Hong

Hoyman M. Hong, MD
Physical Medicine & Rehabilitation
Pain Management and Electrodiagnostics
A Consent Form for Treatment
The purpose of this consent for treatment is to protect your access and our ability to
prescribe you controlled (scheduled) medications in the care of your medical condition.
The long-term use of such substances as narcotic pain medications (opiate analgesics),
benzodiazepine tranquilizers, and sedatives is controversial because of uncertainty
regarding the extent to which they provide long-term benefit. There is the risk of an
addictive disorder developing or of relapse occurring in a person with a prior addiction.
The extent of this risk is not certain but is generally considered to be no more than the
incidence in the general population.
As these medications have potential for abuse or diversion, strict accountability is
necessary especially when utilization is prolonged. For this reason the following policies
must be agreed to by you, the patient, as consideration for, and a condition of, the
willingness of the physician to consider the initial and/ or continued prescription writing
of controlled substances to treat your medical illness.
Initial
_____ 1. I agree to treatment with: Hoyman Hong, M.D.
_____ 2. All controlled substances must come from the physician identified in the consent
form, or during his/her absence, by the covering physician, unless otherwise
specified for exception.
_____ 3. I agree to whenever possible obtain my prescribed medications from this office
at the same pharmacy.
_____ 4. I agree to update this office of any new medical diagnoses or medications as
well as any adverse side effects I experience.
_____ 5. My prescribing physician has your permission to discuss all diagnostic and
treatment details with dispensing pharmacists and/or other medical professionals
who are involved in your health care.
_____ 6. I understand and agree not to share, sell, or otherwise permit others to have
access to my medications.
_____ 7. I agree to safeguard my prescription medications from individuals including
family members as well as any children. I recognize that these medications may be
hazardous or lethal to a persons who is not tolerant to their effects such as children.
_____ 8. I accept and understand that if I abruptly discontinue or stop my prescription
pain medications an abstinence syndrome (withdrawal) will likely develop.
_____ 9. I agree to unannounced urine or serum toxicology screens (drug testing). I
further understand that the presence of unauthorized substances or other illegal
drugs may be grounds for discharge the medical practice.
_____ 10. I will be prepared to bring in the original prescription bottles to each office
visit.
11. I understand that my medications may not be replaced if they are accidently
_____ lost, damaged or destroyed. An exception may be made if your medication has
been stolen. A police report regarding the theft must be provided for the file.
_____ 12. I agree and understand that my prescriptions may be issued early if I or the
physician is unavailable when a refill is due. An appointment will be made for the
next mutually available time.
_____ 13. I agree and understand that my prescriptions for pain medications will typically
be contingent on maintaining regularly scheduled appointments and that early
refills will generally not be given.
_____ 14. I authorize the provider to cooperate fully with any local municipal, city, state
or federal law enforcement agency in the investigation of any possible misuse, sale,
or other diversion of my pain medication. I further agree to waive any applicable
privilege or right of privacy or confidentiality with respect to our cooperation in a
formal investigation.
_____ 15. I understand that in chronic conditions prescription pain medication
management is one form of treatment and its continued use is contingent on
evidence of benefit.
_____ 16. I understand that failure to adhere to these policies may result in cessation of
therapy with the controlled substance prescribed by this office and physician.
_____ 17. I affirm that I have full right and power to sign and be bound by this
agreement, and have read, understood, and accept all of its terms.
__________________________
Patient Name (printed)
__________________________
Patient Signature/Date
34 N. San Mateo Drive, Ste. 2
San Mateo, CA 94401
Phone: (650) 513-6651
Fax: (650) 350-4395
909 Hyde Street Ste. 419
San Francisco, CA 94109
Phone: (415) 796-3371
Fax: (415) 829-8897