(ADHD Medication) and Informed Consent Form
Stimulant medications are federally controlled substances because they can be abused or lead to dependence or withdrawal. Our department provider would like to bring to your attention that the new Senate Bill, SB482, requires checking the national data base for other sources of prescriptions on a regular basis. It is the clinic policy to check a urine drug screen prior to starting medication for new patients or new prescriptions. We may also check urine drug screens on a random basis. It is the clinic policy to prescribe no more than a 3 month supply. Refills must be approved by the provider for each request. When you are 3 days away from being out, please call the pharmacy number on the prescription bottle or generate a request online via kp.org. Prescriptions for stimulants will only be released if you agree to this treatment contract. If you are in the office, it is expected that you sign the contract or if you are receiving this message via secure message (email), please respond with your agreement. If we proceed with stimulant treatment and no response is received within 30 days, it will be assumed that you accept the terms of the treatment agreement.
With consenting to start this medication, you are agreeing to the following:
This consent is all encompassing for all patients across the lifespan this includes Geriatric patients ( age 65 thru 120 years of age) adults (age 18 – 64 years old) Pediatrics ( age 4 to age 12) & Adolescents( age 13 to 17 years of age) that patients (or their guardians) receiving prescriptions for controlled substances be required to sign a Controlled Substance Agreement. By signing this agreement, I agree, or I agree to following:
  • I agree that the patient will take the medication ONLY as prescribed and the dose will NOT be changed without getting approval from my physician or provider.
  • I agree not to share, sell, or otherwise dispense this medication to anyone else.
  • I agree not to seek ADHD medicine from any other source, including other physicians, emergency departments, or clinics.
  • I understand this medication has potential side effects including but not limited to appetite suppression, headaches, stomach pain, irritability or other temporary behavior changes, and difficulty sleeping. These are less if the medications are prescribed to me in a controlled setting under close monitoring by my doctor or provider.
  • I understand that after initiation of treatment, a follow up visit is required within 30 days, and then every 3 months after that. There are no exceptions to this rule. No refill of the medication prescribed for ADHD can be made if these follow-up visits are not kept.
  • I understand that refills of the medication are authorized once every thirty days if the required follow-up office visits are kept. I will not be provided a refill prescription prior to this thirty-day period. Refill prescriptions cannot be mailed, faxed, or called in to the pharmacy. The prescription must be picked up at the office by the patient or another person for whom written consent is in the file.
  • I understand that to obtain a refill, I must call the clinic Monday-Friday 8:00 am to 4:30 pm the day before the refill expires, to request a refill to be picked up the next day the office is open. It is important to make sure that the patient has enough medication to get through weekends, holidays, or after hours because the provider on call will not refill these prescriptions.
  • I will notify the provider if he or she is being prescribed other controlled substances (i.e. opioids, benzodiazepines, sedatives, etc.), including those prescribed by non-Kaiser providers. It will be up to the provider whether stimulants may be prescribed concurrently with these medications, or the dose may be changed due to the risk of adverse side effects.
  • Lost or destroyed medication may be replaced only once. Provider may replace stolen medication if I can present a police report of the theft, and this will only be done once. For any further losses, the stimulant may be tapered and discontinued.
  • I will not use illegal drugs. If illegal drug use is suspected, the provider will stop prescribing the medication.
  • I consent to the cannabis policy.
  • I consent to periodic random urine samples for drug testing. If the urine drug screen is not obtained in the time frame requested by the provider, the provider will stop prescribing the stimulant.
  • I give permission to the provider to coordinate care with the primary care physician and other specialists involved in his or her care
  • I will not obtain stimulants from other sources. If there are multiple sources of stimulants, the provider will stop prescribing the stimulant.
  • I know that this medication is given to help control the effects of ADHD. It is not a cure. The duration of use is determined by the effectiveness of the treatment.
  • I understand this medication is potentially addictive and chances of addiction are less if the medications are prescribed to me in a controlled setting under close monitoring by my doctor or provider. This requires regular office visits and or telemedicine visits to follow my progress.
  • I agree that this medication will be stopped if my ability to function does not improve, if the medication loses its effectiveness, if I do not attend required office appointments, or if there is reason to believe I am misusing the medication in anyway.
  • I have had the risks associated with taking this medication explained to me and have decided that the benefits outweigh the risks.
  • If I am unable to take the medication due to allergic or otherwise adverse reaction, I will notify the prescriber and discard the remainder.
  • I understand that if any of this medication needs to be discarded, I contact my local police department to locate a drug disposal location.
  • I authorize Priority Medical Group to review medication information with other doctors, hospitals, and pharmacists; additionally, to contact any groups and organizations involved with my care and involved with the investigation of medication and drug abuse. I give permission to my provider to discuss my care with past caregivers, all pharmacies, and policing agencies.
I have read, reviewed, and understand the contents of this consent, have had an opportunity to ask questions and acknowledge by signing this document I will follow and be bound to the above rules of this consent.