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Pain management agreement - UC Health Pain Management Center 2026

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The document is a Pain Management Agreement between a patient and the UC Health Pain Management Center, outlining the responsibilities and expectations for both parties regarding the use of controlled substances for chronic pain management. It emphasizes adherence to prescribed dosages, attendance at appointments, compliance with treatment plans, and the prohibition of illegal substance use. The agreement also details the risks associated with opioid medications and stipulates conditions under which prescriptions may be altered or discontinued.

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Click ‘Get Form’ to open the Pain Management Agreement in the editor.
Begin by entering your Patient Information, including your MRN and Date of Birth in the designated fields.
In the section labeled 'Pain Management Agreement', fill in your name and MRN number as well as the name of your provider.
Carefully read through each condition outlined in the agreement. You may need to check boxes or sign where indicated to confirm your understanding and acceptance.
Complete any additional sections regarding medication refill information, ensuring you understand the requirements for refills and appointments.
Finally, sign the document at the bottom along with a witness and your provider, ensuring all signatures are captured before submission.

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Versions	Form popularity	Fillable & printable
2009	4.4 Satisfied (39 Votes)
2006	4.6 Satisfied (37 Votes)

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