SAMPLE TREATMENT AGREEMENT
Treatment Agreement between __________________________________ and Integrative Practitioners Medical Marijuana Program.
This Treatment Agreement helps both of us, our Practice and you, our Patient. It spells out our responsibilities to you, NYS requirements for use of Medical Marijuana (MM) and what you need to do to to hold up your end of the agreement.
Our goal is simple – to assess you to see if you meet the New York State requirements to be registered as a Medical Marijuana Patient and to help you get the most benefit possible from the program.
You have choices – after meeting with us, you could decide that MM is not for you or that you would like to meet with another provider for an assessment. You might decide that using MM will make an existing problem with substance abuse worse. In that case we will be glad to refer you to programs and centers for such treatment.
Our treatment here at Integrative Practitioners is to ONLY certify and register you as a Medical Marijuana Patient. We do not provide any other type of health care, including prescriptions.
The result we want to see is that using MM will improve your level of functioning and ability to work and engage in everyday activities. Other results are improved mood, less pain and better sleep. We also hope it will help the symptoms of your condition as much as possible without causing dangerous side effects and to reduce or eliminate your use of other medications (like opiates) with a high risk for misuse.
There are risks to using Medical Marijuana, and by signing this Treatment Agreement you are acknowledging you have been informed of these risks, given an opportunity to ask questions and are willing to proceed knowing the risks.
Most importantly, you must be aware of and acknowledge the following risks and concerns (known and unknown) associated with using MM:
1. Drinking alcohol or using street drugs along with MM might impair your ability to think clearly or react in an emergency situation.
2. You may get psychologically dependent on MM especially if you or a close family member has a known history of drug or alcohol problems.
3. Know that we STRONGLY encourage you to avoid driving,operating machinery, caring for small children or engaging in activities that might be dangerous for yourself or others while using the psychoactive component (THC) of MM.
4. That MM might make existing mental health symptoms (anxiety,depression,etc.) worse.
5. Know that MM may not work as desired for everyone but we will do our best to work with you to find a combination and dosage that is effective. There are no guarantees.
In signing this Treatment Agreement you acknowledge you understand ALL of the following points, agree, and have had any questions answered:
You must have a referral from a NYS Provider along with labs to be considered for the program.
You must have submitted our Health Assessment Form and attest that the information is true and correct.
You must give us a list of your current medications AND update us on changes or new prescriptions for controlled substances.
You do not have any of the conditions that exclude you from using MM.
You reside in NY and your primary health care is provided in NYS.
You agree to keep in contact with us regarding your progress, need for dosage changes and in keeping all follow-up appointments. If you do not call or show for an appointment you will be dropped from our program.
You will NOT share, trade or sell any MM products.
You will keep your MM in a safe place, out of the reach of children.
You will bring your MM products to each appointment.
You know that your MM cannot be renewed, replaced if lost or stolen or used up before the appropriate period (usually monthly).
You agree to random urine or blood screenings for drugs of abuse.
You know that we check the NYS Controlled Substances Registry to see what controlled substances (including MM) are prescribed to you.
You agree to inform other health care providers that you use MM and that we may verbally discuss your treatment plan with those providers. You know that we will report on your the results of your consultation and treatment plan to the referring provider. If we need to see your medical records or other providers want to see our records you will sign a release of information.
If you stop using MM or are discharged from our practice you understand that you must turn in your State MM card within 5 business days.
If you do not hold to this agreement you will be discharged from our care. If we find that MM is no longer helping or actively hurting you, your certification will be withdrawn. If we (or you) feel you are using MM inappropriately we will help you find a program or provider that will work with you to address this problem.
We can also withdraw your certification at any time without cause. If any of those things happen you are free to seek certification from another NYS registered provider.
I have been informed of the risks of using MM, understand this Treatment Agreement, have had an opportunity to ask questions and agree to abide by these Agreements.
600 East Genesee Street, Suite #114
Syracuse, NY 13202
fax 315.221.9736 or 315.825.4303
Copyright 2017 - all rights reserved.
Site Photographs - Carol Disalvo Photography - www.caroldisalvophotography.com