Thrive
Benzodiazepine Management Agreement
The decision to use benzodiazepine medications was made between my provider and myself because of my specific condition.
When I sign this form, I acknowledge that I understand and agree to the following conditions to make my treatment as safe and successful as possible:
1.) I am aware that the use of such medicine has certain risks associated with it, and I have reviewed the Benzodiazepine medication handout with my provider.
2.) I agree to help myself by following better health habits: exercising, controlling my weight, seeking long-term treatments for anxiety, and avoiding the use of alcohol and tobacco, because I realize that good health habits help me control my anxiety and depression.
3.) I agree to tell my doctor about all other medicines and treatments that I am receiving.I will not request or accept controlled substances/medications from any other physician or individual without talking about it with my provider while I am receiving a benzodiazepine medication (while I am receiving such medications from my provider.
To do so may endanger my health and our provider-client relationship. The only exception is medication prescribed while I am admitted to a hospital.
4.) I understand the following refill policy will apply, unless I have made previous arrangement with my provider:
a. Medications will not be refilled early, even if they have been lost, stolen, or destroyed.
b. Medications will not be refilled on Fridays, weekends, or holidays.
c. Medications will not be refilled by other physicians or providers.
5.) I agree to use only one pharmacy for all my medications. If I change pharmacies for any reason, I agree to notify my provider at the time I receive a prescription and inform my new pharmacy of my prior pharmacy’s address and telephone number.
6.) I agree to keep all scheduled appointments.
7.) I must keep my provider fully informed of any changes, ER or PES visits, lost or stolen medications or any other circumstances affecting my health and well-being.
8.) I have been fully informed by my provider regarding the potential psychological dependence on a controlled substance. I know that some persons may develop a tolerance, which is the need to increase the dose of the medication to achieve the desired effect. I know that I may become
physically dependent on the medication. This will occur if I am on the medication for several weeks; when I stop the medication, I must do so slowly and under medical supervision or I may have withdrawal symptoms.
9.) I understand that if I fail to comply with the guidelines in this agreement and on my prescription labels; if I obtain controlled substances elsewhere (even from a physician); if I use illicit drugs; if I share controlled substances with others; or if I alter a prescription, our provider-client relationship will be terminated.
Here at Thrive MHS, providers do not prescribe benzodiazepines for long-term use
I have read and understand the consequences of violating this agreement. My provider has answered my questions and I agree to the terms of the agreement.
***I acknowledge understanding and receipt of the above information. I understand that a copy of my consent forms can be accessed at any time through my patient portal account or printed for me by office staff at my request.