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Practice form example

Controlled substance agreement

An illustrative outline of elements a controlled-substance treatment agreement commonly includes. This is educational only and is a sensitive, high-liability area.

Download the PDFPDF, 1 page, 4 KB. Free, no sign-up. For clinicians.
Educational example only. This is not legal, medical, or compliance advice, and it is not a ready-to-use legal document. Requirements vary by state, payer, and setting. Adapt anything like this to your own situation and have it reviewed by qualified legal and compliance counsel licensed in your jurisdiction before using it in a practice. You are responsible for compliance with all applicable federal and state laws, including HIPAA. shrinkiatry publishes professional commentary and education, not legal or medical advice.

Extra caution: Do not use this as a policy without review. DEA and state controlled-substance rules, and telemedicine prescribing flexibilities, change frequently.

Current as of July 7, 2026. Laws, payer rules, and billing codes change, so confirm the current requirements for your jurisdiction and setting before you rely on it.

What's inside

Common elements

  • One prescriber and one pharmacy for the controlled medication
  • Prescriptions filled on schedule, with no early refills for lost or missing medication except at the clinician's discretion
  • Agreement to prescription drug monitoring program (PDMP) checks and, where used, urine drug screening
  • Safe storage, and no sharing or selling
  • How refills are requested, and expected visit frequency
  • Circumstances that may end the agreement or the prescription

Notes for the clinician

Controlled-substance prescribing is governed by federal DEA rules and state law, both of which change. Telemedicine prescribing of controlled substances has specific, evolving requirements. Confirm current rules for your setting before relying on any template.

About this resource

This template is part of the shrinkiatry resource library, a set of free, clinician-facing references and examples. It's reviewed by Shariq Refai, MD, MBA, FAPA, a board-certified psychiatrist, on a quarterly schedule. Next scheduled review: October 1, 2026. First published July 7, 2026, last reviewed July 7, 2026.

Browse the rest of the resource library, or verify who reviews this site. Spotted something out of date? Email corrections@shrinkiatry.com.

Educational and professional commentary only. shrinkiatry explains the profession of psychiatry. It doesn't provide medical advice, isn't a substitute for evaluation or treatment by a licensed clinician, and reading it doesn't create a doctor-patient relationship.