Prescription Monitoring Program

Please initial in acceptance of the following points:
* Required Information
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.
I understand that in certain situations I may be tested in order to receive prescription narcotic medication.
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.
I understand that this information is part of my medical records.
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.
Patient Name
*Patient Signature
Please sign above:
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.