The following agreement relates to my use of controlled substances for chronic pain prescribed by a physician at the Athens Spine Center. I recognize that there are policies regarding the use of controlled substances which are followed by the staff at Athens Spine Center. I will be provided controlled substances while actively participating in this program only if I adhere to the following regulations:
Georgia Pain Rule 360-36-.6 dictates that any physician in the state of Georgia who prescribes pain medication (controlled substances) for 90 days must monitor that patient for medication usage. Patients are required to comply with this mandatory testing either during a scheduled office visit or by coming into the office for the sole purpose of drug screening within any 90 day period. Patients are responsible for checking with their insurance carrier regarding any co-payments or deductibles that apply to medication monitoring/drug screenings.
**Must be signed in presence of witness