MIRACLE HILLS PRIMARY CARE CENTER
PAIN MANAGEMENT CONTRACT
In order receive a prescription for pain medication from a Miracle Hills Primary Care Center
physician, you must read and agree to the following:
The patient agrees to only receive pain medicine prescriptions from a Miracle Hills Primary Care
Center Provider.
The patient further agrees to not seek pain medication from another provider, emergency room or
urgent care facility.
The patient agrees that he will not request early refills for pain medication.
The patient agrees that if the pain medication is lost, stolen or destroyed, he will not receive
replacement medication from Miracle Hills Primary Care Center. In the event of stolen
medication the patient agrees to file a police report and bring a copy of that report to Miracle
Hills Primary Care Center.
The patient agrees to take the medication as directed by the prescription. He will not take extra
medication or take the medication dose early.
The patient will keep all return appointments faithfully. Medication will be refilled on a monthly
basis.
We, at Miracle Hills Primary Care Center take prescribing pain medication seriously. We want
our patients to take the medication as prescribed. In order to monitor our patients and their pain
medication, we will schedule regular appointments to evaluate their progress and the current
status of their pain.
We do not prescribe pain medication for an extended period of time. If the patient is not
responding to pain management medication as we would like him to, we will refer him to a Pain
Management Specialist. If the patient’s condition does not improve in a reasonable period of
time, we will refer him to a Pain Management Specialist.
By signing this document, the patient agrees to abide by the rules set forth in this document.
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Patient
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Witness
Date:_____________________________