FORM #2 - MEDICATION PRESCRIPTION PATIENT CONTRACT This notice describes how medical information about you may be used, disclosed, and how you can get access to this information. Notice of Information PracticesTemah Healthcare Services agrees to provide the undersigned patient with narcotic medication when the patient agrees to the following: Patient agrees to Use only Temah Healthcare Services Provider (THS) for Narcotic Prescriptions. You cannot see any other provider for Narcotic Prescription. Use one pharmacy to fill prescriptions. Take all prescription medication as directed by THS providers Present prescription bottles for pill count at each visit when asked Be responsible to protect the prescriptions and medications provided Paying cash for any medication will result in closing your visits from THS and reported as medication fraud Be available for random monthly drug screening Understands the violation of any once of the above direction, will cause termination of Narcotic prescription writing by THS Name* First Last Signature* Enter full nameDate* MM slash DD slash YYYY HiddenWitnessHiddenName First Last HiddenSignature Please, sign in space provided.HiddenDate MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
