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Prescription Refill Policy

  • Your prescription needs can be taken care of as part of your regular office visit, at no extra charge.

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  • Our providers make every effort to provide long-term prescriptions and automatic refills at that time, to avoid you having to contact us separately to request a refill.

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  • Please be aware that refills take valuable staff and provider time to address.

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  • ALL patients who request prescription refills at any time other than an office visit are charged a service fee that varies based on the number of medications.

     

  • This includes prescriptions that need to be written, called in, electronically sent, faxed and/or mailed to the pharmacy.

 

  • Service fee for prescription refills is $5 per prescription, this fee is due at the time of service.

Appointment Cancellation Policy

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  • We confirm ALL appointments made.

 

  • We need a good phone number to contact you at any time.

 

  • If you need to cancel/change an appointment, our office requires a 24-hour advanced notice so that appointment time can be offered to another patient.

 

  • Failure to provide this notice will result in a $35.00 fee.

 

  • Patients will be responsible for this fee not their insurance.

 

  • Failure to pay that fee may result in termination of services.

Controlled Substance Policy

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                                           SunRise HealthCare

                                          1171 W. Tipton St., Seymour, IN 47274

                                       Phone: 812-405- 2125 Fax 812-405- 2425

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  • The purpose of this agreement is to protect your access to controlled substances and to protect our ability to prescribe for you.

 

  • Because these drugs have potential for abuse or diversion, strict accountability is necessary when use is prolonged. For this reason the following policies are agreed to by you, the patient, as consideration for, and a condition of, the willingness of the provider whose signature appears below to consider the initial and/or continued prescription of controlled substances to treat your chronic pain.

 

  • All controlled substances must come from the provider whose signature appears below or, during his/her absence, by the covering physician, unless specific authorization is obtained for an exception.

 

  • All controlled substances must be obtained at the same pharmacy. The pharmacy that you have selected is:__________________________________________________________

 

  • SunRise HealthCare does not prescribe OxyContin or OxyIR, manage pain pumps or accept patient from Methadone Clinics.

 

  • You may not share, sell, or otherwise permit others to have access to these medications.

 

  • Unannounced urine or serum toxicology screens may be requested, and your cooperation is required. Presence of unauthorized substances or lack of presence of prescribed medications may result in discontinuation of controlled substances and discharge from this practice.

 

  • You may be called for a random pill count and you must present with your prescriptions by the end of the day that you are called. Failure to do so will result in discontinuation of controlled substances and discharge from this practice.

 

  • You must maintain a working phone number in your chart at all times. If we are unable to reach you for a pill count you will no longer receive narcotics and will likely be discharged from our care.

 

  • If you are going to be out of town during the week, it is important to call the office and notify our staff that you will be out of town. If we call you for a pill count and you have not informed us of being out of time prior to our call and you are unavailable for your pill count you will no longer receive narcotics and will likely be discharged.

 

  • It is the patient’s responsibility to take the highest care to safeguard your medications and prescriptions.  Medications will not be replaced if they are lost, get wet, are destroyed, stolen, etc.

 

  • Early refills will not be given. Refill requests will only be addressed at appointments.

 

  • It is understood that failure to adhere to these policies may result in cessation of therapy with controlled substances prescribed by this provider or referral for further specialty assessment.

 

  • Renewals are contingent on keeping scheduled appointments, including but not limited to diagnostic tests, chiropractic care and physical therapy.

 

  • It is also required that all patients arrive 15 minutes before their scheduled appointment in an effort to keep everyone on schedule and allow all patients equal appointment time. If you do not arrive 15 minutes before your scheduled appointment you will be rescheduled to the next available appointment time.

 

  • It should be understood that any medical treatment is initially a trial, and that continued prescription is contingent on evidence of benefit.

 

    __________________________________                    ______________________________

    Witness Signature                                                            Patient Signature

  

   __________________________________                     ______________________________

    Date                                                                                 Patient Name (Printed)

 

Revised 1/22/15

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