Prescription Monitoring Program
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Provider Name
*
Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.
*
Proporcione su nombre legal completo tal como aparece en su licencia de conducir, tarjeta de identificación estatal o identificación emitida por el gobierno tarjeta.
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* Required Information
* Información requerida
Prescription Monitoring Program
Programa de Control de Medicamentos
Please initial in acceptance of the following points:
Por favor, ponga sus iniciales para aceptar lo siguiente:
*
I understand that OACT has instituted a prescription drug monitoring program designed to protect the patient, the community and the physician in the instance in which a narcotic pain medication is or will be prescribed.
Entiendo que OACT ha establecido un programa de control de medicamentos recetados desarrollados para proteger el/la paciente, la comunidad y el médico en la ocasión que un medicamento narcótico para el dolor es, o será, prescrito.
*
I understand that in certain situations I may be tested in order to receive prescription narcotic medication.
Entiendo que en algunas situaciones yo puedo ser evaluado(a) antes de recibir medicamentos narcóticos recetados.
*
I understand that results of my screening are utilized only to determine the ability of the physician to prescribe dangerous narcotics medication and may not be disclosed to anyone I have not provided authorization to receive that information.
Entiendo que los resultados de mi examen se utilizan únicamente para determinar la capacidad del médico para recetar medicamentos narcóticos peligrosos, y que no pueden ser revelados a nadie a quien yo no haya dado autorización para recibir esa información.
*
I understand that this information is part of my medical records.
Entiendo que esta información forma parte de mi historial médico.
*
I understand that if I refuse to participate in the prescription screening program that the physician may not prescribe narcotic pain medication but prescription alternatives.
Entiendo que si me niego a participar en el examen para el control de medicamentos recetados, el médico no podrá recetar medicamentos narcóticos para el dolor, sino recetas alternativas.
Patient Name
Nombre de paciente
*
Patient Signature
*
Firma de paciente
Please sign above:
Por favor, firme arriba
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