Controlled Substance Treatment Agreement

> Important: This agreement applies only when controlled-substance treatment is clinically appropriate and offered by a Siya Healthcare, PLLC clinician. Signing this agreement does not guarantee diagnosis, medication, or stimulant prescribing.

Introduction

This agreement outlines the expectations, responsibilities, and policies related to the prescribing of controlled substances through Siya Healthcare, PLLC. By signing below, you agree to comply with all terms as a condition of receiving controlled-substance treatment when clinically appropriate.

Siya Health Inc. provides administrative and non-clinical support services. Medical services, including controlled-substance prescribing decisions, are provided by Siya Healthcare, PLLC through licensed clinicians where Siya Healthcare, PLLC offers services and where the treating clinician is authorized to prescribe.

Controlled Substance Evaluation Process

Controlled substances are not prescribed during the initial evaluation visit.

The initial appointment is used for mental health intake, medical history review, symptom discussion, review of prior records when available, and a general clinical assessment.

As part of this practice's controlled-substance prescribing process, patients may be required to complete objective cognitive, behavioral, symptom-based, or diagnostic assessments determined by the treating clinician. Additional records, testing, documentation, or follow-up visits may also be required.

All testing results, clinical findings, medical history, prior records, and other relevant information are reviewed by the treating clinician and correlated with the overall clinical presentation before treatment recommendations are made.

Completion of an evaluation, testing process, or follow-up visit does not guarantee a diagnosis, controlled-substance prescription, stimulant prescription, or any specific treatment recommendation.

Controlled medications, when clinically appropriate, may only be considered after completion of the required evaluation process, review of all relevant information, assessment of contraindications and safety concerns, and a subsequent clinical visit. Prescribing decisions remain subject to provider clinical judgment, patient safety considerations, applicable laws, regulatory requirements, and practice policies.

Treatment & clinical evaluation requirements

• Mandatory clinical evaluation and assessment. Prior to initiation or continuation of controlled-substance treatment, you must complete a comprehensive clinical evaluation and assessment protocol, including all assessments and forms required to justify prescribing. No prescriptions issue without completion and provider review. This complies with clinical and legal standards where Siya Healthcare, PLLC offers services and where the treating clinician is authorized to prescribe.
• You must attend regular follow-up appointments (via telehealth or in person, as required) before the fourth week of each month for prescription review, effectiveness assessment, side effect monitoring, and necessity evaluation.
• Report any side effects, concerns, or desire to discontinue immediately. Failure to attend may result in prescription discontinuation.
• Your provider will regularly assess the effectiveness, side effects, and necessity of continued treatment.

Prescription filling and pharmacy policies

• Prescriptions may take up to 5 business days from the date the prescription is sent to the pharmacy by the provider, due to prior authorizations, pharmacy mismatches, or administrative needs. Exercise patience and avoid seeking medications elsewhere without consultation; contact us after 5 days if unfilled.
• Only your Siya Healthcare, PLLC provider may prescribe controlled medications for your condition.
• You will not obtain similar medications from any other provider unless explicitly approved.
• You will use only one (approved) pharmacy unless an emergency occurs, in which case you will notify your provider.
• Lost, stolen, or destroyed medications will not be replaced. Early refills are not permitted.

Drug monitoring & compliance

• You consent to random urine drug screening (UDS) as part of your care when clinically indicated.
• A UDS that is positive for unauthorized substances or negative for your prescribed medication may result in immediate termination of controlled-substance prescribing.
• Your provider will review applicable state prescription drug monitoring programs (PDMPs), including PA-PDMP where applicable, on a regular basis as required for your care.
• You may be asked to complete pill counts or other compliance checks at any time.

Safe & responsible use

• You will take your medication exactly as prescribed and will not share, sell, or misuse it.
• You will store your medication securely to prevent loss, theft, or misuse.
• You will inform your provider before taking any new medications, including OTC drugs and supplements.
• In emergencies, call 911—electronic communications are not for urgent issues.

Non-compliance & termination

• Missed appointments, refusal of UDS when clinically required, PDMP irregularities, or evidence of misuse may result in treatment termination.
• Non-compliance with controlled substance protocols may result in immediate suspension or termination of prescriptions and services.
• You understand that this agreement is required for controlled-substance treatment when offered and that violations may result in permanent discontinuation of controlled prescriptions.

Related policies

This agreement supplements the Terms of Use, Privacy Policy, and Notice of Privacy Practices. Controlled medications are not stored or dispensed at any Siya office.