PAIN MANAGEMENT AGREEMENT AND ALLIANCE

THE FOLLOWING  IS AN AGREEMENT  BETWEEN THE TREATING  PROVIDER  PRESCRIBING OPIOIDS AND OR MEDICATIONS WITH  STRONG  POTENTIAL FOR DEPENDENCE AND  HIS OR  HER  CLIENT(PATIENT). THE GROUP MAY TAKE ACTION WHICH CAN BE  IMMEDIATE IF  THE  MANAGEMENT  AGREEMENT   IS  BROKEN IN  ANY ASPECT OR IF THE RESPONSIBLE PROVIDER DEEMS IT APPROPRIATE. OUR PRIMARY GOAL REMAINS TO IMPROVE THE OVERALL QUALITY OF LIFE BY IMPROVING FUNCTIONAL LEVELS OF INDEPENDENCE IN  DAILY ACTIVITIES AND MOBILITY THROUGH  MULTIPLE MODALITIES.  
 
CONSEQUENCES IN THIS REGARD  (TO THE ABOVE) WILL BE EXPLAINED BY  A MEMBER OF  THE   HEALTHCARE  TEAM  AT TF (Top Flight Medical Group, LLC) . THE  EXPLANATION IS  MEANT  FOR THE  PATIENT (CLIENT),  REFERRING  PROVIDER,  PHARMACY, AND SPONSORING INSURANCE COMPANY AS APPROPRIATE. TF BELIEVES  THE RULES AND  GUIDELINES TO BE APPROPRIATE  FOR BEING  INCLUDED IN THE PAIN MANAGEMENT PROGRAM. THEY ARE INTENDED TO HELP ONLY. THEY ARE ALSO BELIEVED TO BE  VITAL TO THE INTEGRITY OF THE  CHRONIC (SIGNIFICANT PAIN EXPECTED TO CONTINUE BEYOND 6 WEEKS OF ITS BEGINNING) PAIN MANAGEMENT, SAFETY  OF  OUR CLIENTS AND  VERY MUCH FAIR.


I MAY  RECEIVE  OPIOIDS AND OR MEDICATIONS WITH  DEPENDENCE POTENTIAL WHILE ACTIVELY PARTICIPATING IN THE  PROGRAM ONLY IF  I FOLLOW THE  RULES LISTED BELOW: PLEASE  CHECK BOXES
Please check the  box   at the bottom of the  program rules, thus indicating that  you  have  read and  do agree to adhere to each of the rules.

PROFANITY  , VOICE  RAISING, THREATS, AND OTHER EXAGGERATED BEHAVIOR DIRECTED AT  PROVIDERS, STAFF OR  ANY OTHER PERSON ON THE CLINICAL  OR BUSINESS  PREMISES WILL BE  GROUNDS FOR IMMEDIATE RELEASE FROM THE GROUP *
I UNDERSTAND THAT IF I GO TO AN EMERGENCY DEPARTMENT THAT I MAY POTENTIALLY BE PLACED ON OPIOID (PAIN) MEDICATIONS WHILE THERE AND THAT I MAY BE GIVEN A PRESCRIPTION OF OPIOID (PAIN) MEDICATIONS. IF ANY OF THE ABOVE OCCURS, I AGREE TO CONTACT THE TOP FLIGHT MEDICAL GROUP VIA PHONE, EMAIL, OR OTHER MEANS TO MAKE THE GROUP AWARE AND TO OBTAIN APPROVAL OR ADVICE OTHERWISE AS SEEN APPROPRIATE FOR MY PARTICULAR CASE. I MAY UNDERGO ANY RECOMMENDED TREATMENT THAT I CHOOSE AS LONG AS THE SERVICES ARE CARRIED OUT WHILE IN THE EMERGENCY OR URGENT CARE FACILITY. ANY FILLING OF OPIOID/NARCOTIC/PAIN MEDICATIONS MUST BE CLEARED BY THE TOP FLIGHT MEDICAL GROUP PRIOR TO FILLING. *
I UNDERSTAND THAT I MAY BE  GIVEN A SUPERVISED URINE  OR BLOOD DRUG SCREENING TEST  AT  ANY TIME  IN  ORDER TO CHECK  IF I AM FOLLOWING THE RULES *
I  UNDERSTAND THAT  PSYCHOLOGICAL  EVALUATION AND  OR  FOLLOW-UP MAY BE REQUIRED BY TF FOR  OPIOID MAINTENANCE *
I UNDERSTAND THAT I MUST  BE SEEN  BY MY PAIN  MANAGEMENT   PROVIDER REGULARLY. THIS REQUIRES A SCHEDULED VISIT TO THE  CLINIC. REFILLS WILL NOT BE MADE IF I DO NOT KEEP  AN APPOINTMENT *
I MUST  NOTIFY MY TF  PROVIDER OF ANY CHANGES IN PAIN  STATUS AND  OF ANY DOSAGE OR  SCHEDULE CHANGES IN THE  ADMINISTRATION OF THE PRESCRIBED MEDICATION MADE BY MYSELF OR OTHER PROVIDER *
IF  AT  ANY TIME I EXPERIENCE A LOSS OF CONTROL OF MEDICATION  INCLUDING  LOST  PRESCRIPTION(S), MEDICATION, STOLEN OR MISPLACED MEDICATION,  I MAY BE RELEASED FROM MANAGEMENT  BY TFMG *
LOST OR STOLEN OPIOID (NARCOTIC-PAIN) MEDICATIONS OR PRESCRIPTIONS WILL NOT BE REPLACED. ALSO, THE TF GROUP WILL NOT CONTINUE OPIOID PRESCRIBING AT ALL, AND WILL ON A CASE BY CASE BASIS OFFER OTHER APPROPRIATE OPTIONS IF ANY EXSIST *
ANY  PRESCRIPTION OR MEDICATION THAT IS OR   THAT  APPEARS TO BE  STOLEN,  MUST BE  REPORTED  TO  LOCAL  POLICE  AGENCIES APPROPRIATELY. A COPY  OF THE  REPORT  MUST BE  MADE AVAILABLE TO TF.  REPLACEMENT  PRESCRIPTIONS WILL NEVER  BE GIVEN HOWEVER *
I UNDERSTAND THAT  COMBINING OTHER MEDICATIONS WITH OPIOIDS  MAY CAUSE DROWSINESS, INTOXICATION, OR DEATH. SOME OF THESE MEDICATIONS ARE TRANQUILIZERS( DOWNERS), STIMULANTS (UPPERS), DIET PILLS, SLEEPING  PILLS, ALCOHOL. OR  OTHER STREET  DRUGS *
I UNDERSTAND THAT  COMBINING OTHER MEDICATIONS WITH OPIOIDS  MAY CAUSE DROWSINESS, INTOXICATION, OR DEATH. SOME OF THESE MEDICATIONS ARE TRANQUILIZERS( DOWNERS), STIMULANTS (UPPERS), DIET PILLS, SLEEPING  PILLS, ALCOHOL. OR  OTHER STREET  DRUGS *
I CAN BE RELEASED  FROM THE  GROUP IF  I MISS A SCHEDULED APPOINTMENT WITH TF OR WITH ANY OTHER ENTITY THAT TF HAS SCHEDULED  FOR ME TO ATTEND (EXAMPLE- AN MRI APPOINTMENT OR A PHYSICAL THERAPY APPOINTMENT) *
I UNDERSTAND THAT  I AM  REQUIRED TO BRING ANY AND ALL MEDICATIONS PRESCRIBED TO ME BY TF TO ANY AND EVERY VISIT TO TFMG OR  WITH TF. THEY SHOULD BE  IN THE  CURRENT  PRESDCRIPTION BOTTLES OR PATCH BOXES OR PACKAGES WITH  LEGIBLE LABELING. IF I KEEP MY MEDICATIONS IN  DAILY PLANNERS, THEN I CAN BRING  THE PILLS IN THE PLANNER, BUT  I MUST STILL  ALSO BRING  IN THE CURRENT PRESCIPTION BOTTLE *
THE  PROVIDER  PRESCRIBING THE MEDICATION RESERIVES THE RIGHT TO DECREASE OR DISCONTINUE THE MEDICATION AT ANY TIME STRICTLY AT  HIS  OR  HER  OWN APPROPRIATE  DISCRETION. AN APPROPRIATE DETOXIFICATION PROGRAM MAY BE  RECOMMENDED IF  DEEMED NECESSARY *
i AGREE TO  USE ONLY ONE PHARMACY TO RECEIVE MY PAIN MEDICATION. IF I CHANGE PHARMACIES, I WILL  INFORM TFMG. IF  MY HOME ADDRESS CHANGES, I WILL CONTACT TFMG AND REPORT THE NEW ADDRESS *
I WILL NOTIFY OTHER  HEALTH PROVIDERS AS WELL AS EMERGENCY ROOM/ DEPARTMENT PROVIDERS THAT  I AM SIGNED TO A PAIN MANAGEMENT  PROGRAM AGREEMENT PRIOR TO TAKING ANY OUTSIDE PAIN MEDICATION PRESCRIPTIONS *
I  WILL RECEIVE  MY PAIN MEDICATION ONLY FROM  A TFMG PROVIDER OR ASSOCIATE, IF I RECEIVE ANY  PRESCRIBED MEDIATION OUTSIDE THE TFMG PROVIDER WITH  RESPECT TO PAIN MANAGEMENT, MY TREATMENT WILL BE  TERMINATED *
I WILL USE THE  MEDICATION ONLY AS PRESCRIBED BY TFMG  PROVIDER. i WILL NOT ALTER ANY DOSAGE UNTIL I HAVE CONTACTED THE PRECSRIBING PROVIDER AND RECEIVED APPROVAL TO DO SO *
I  UNDERSTAND THAT   USING ANY ILLEGAL DRUGS WILL RESULT IN IMMEDIATE TERMINATION BY TFMG *
I CAN BE RELEASED FROM THE PROGRAM IF I FAIL TO ATTEND A CALLED RANDOM   VISIT  WITH TFMG, OR  FOR REASONS  SUCH AS URINE SCREEN OR  PILL COUNT OR  OTHERWISE *
I CAN BE RELEASED FROM THE  GROUP IF I MISS ANY  SCHEDULED APPOINTMENT AT  ANY TIME FOR ANY REASON *

Continued Use of Controlled Medication is based on your physician’s judgment and a determination of whether the benefits to you of using controlled medications outweigh the risks of using them.

I UNDERSTAND THAT IF I USE MORE OF ANY OF THE MEDICATIONS PRESCRIBED, SELL OR  LET OTHER PEOPLE SELL OR  USE OR  COLLECT   OR OBTAIN  MY  PRESCRIBED MEDICATIONS, THAT  THIS  IS NOT  AUTHORIZED  BY TFMG; TFMG MAY REFUSE TO CONTINUE TO PRESCRIBE MEDICATION OF POTENTIL DEPENDENCE  PROVOKING THERAPIES. A REFERRAL TO AN ADDICTION TREATMENT CENTER MAY BE MADE. A MEDICATION CHANGE  MAY OCCUR *

We believe in treating your pain and we recognize the value of controlled medications in this process. When used properly, controlled medications can help restore comfort, function, and quality of life. However, as stated above, controlled medications may also have serious side effects and are highly controlled because of their potential for misuse and abuse. It is important to work with your physician and communicate openly and honestly with him or her about your pain control needs. By doing so, medications can be used safely and successfully.

By your signature below, you are acknowledging that you have read and reviewed these matters with your physician and that you have sufficient information to make a decision to use the controlled medications prescribed.

You should NOT sign this form if you do not believe you have enough information to make an informed decision about your use of controlled medications and how they fit in to your pain management treatment plan. Finally understand that not every person will respond favorably to an opioid or controlled medication regimen of care at all.

BY CHECKING  THE BOX IMMEDIATELY FOLLOWING  I AUTHENTICATE THAT   I HAVE READ THE ABOVE  AGREEMENT AND  UNDERSTAND THE RULES REGARDING PRESCRIBING AND  USE OF  PAIN MANAGEMENT  MEDICATIONS. I AGREE TO COMPLY WITH THE  PROGRAM. I ALSO AGREE TO  ANY APPLICABLE  TESTING  AND  DETOXIFICATION IF NECESSARY *
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SIGN HERE TO AUTHENTICATE THIS AGREEMENT *
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or phone: 615.340.3436/emergencies 615.680.9055