Family and Community Medicine ADD/ADHD MEDICATION CONTRACT

I understand and agree to the following:

I have been prescribed stimulant medication for treatment of Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD).

ADD/ADHD stimulant medications are controlled substances that are regulated by state and federal law because of their high risk for abuse. I understand that it is a FELONY to obtain these medications by fraudulent means, to possess these medications without a legitimate prescription, and to give or sell these medications to others. I acknowledge that it is both illegal and dangerous to share or sell prescription medications.

I will be receiving written ADD/ADHD medications only from my physician listed below or their designee in the event of illness or absence. I will receive the prescription only for the time frame that my physician decides with me (either once a month or if condition is stable as deemed by the physician, once every three months).

I will use my medication as prescribed and not adjust the dosage on my own.

I am responsible for filling and paying for my medications

I will be required to make and keep regular appointment at with my physician for follow up.

I will not receive any medications earlier than they are due.

I will call in at least 3 business days to request my written refill.

Missing appointments will result in the loss of ADD/ADHD prescription privileges.

There will be no replacement of prescriptions/medications that are lost, stolen, misused or damaged and I am responsible for keeping the prescriptions or medications safe from loss, theft and/or damage.

I have read and understood this contract and I agree to fulfill my obligations and understand that any violation of this contract will results in the termination of this contract and loss of ADD/ADHD prescription given by this practice and all of the Family and Community Medicine practices in the University of Missouri-Columba

Patient Name ________________________________ Patient Signature __________________________ Date ________

Provider Name _______________________________ Provider Signature _________________________ Date ________

Sources: Marist college Health Services, Union University Health Services