Evidence status: PUBLIC INSTITUTIONAL FORM / CURRENT DISTRIBUTION PATH UNRESOLVED. Community Health Services continues to host a two-page Controlled Substance Agreement marked Revised 5/21. The organization remains active, but this evidence pass did not establish a live 2026 forms page distributing this exact version.

Quick read

The agreement covers one designated provider, treatment participation, lost/stolen medication, refill appointments, one pharmacy, records release, drug testing and pill counts, a 24-hour response requirement, provider-directed weaning, and loss of treatment for breach.

Who is on the provider side

This is an institutional agreement with a blank field for the patient’s designated provider. Seeds of Vice does not assign the 2021 form to a present-day individual clinician without a source tying that person to the agreement.

Terms that matter most

  • One designated provider manages controlled medication and the patient uses one pharmacy.
  • The patient agrees to participate in treatment requested by the provider.
  • Lost or stolen medication is not replaced until the next appointment and may not be replaced at all.
  • An appointment is required for refills.
  • When called for testing or a pill count, the patient must report within 24 hours; the form says a missed test is considered positive.
  • The provider may decrease or wean medication if the risk exceeds benefit or if treatment of the underlying cause is recommended.
  • The form says breaking any part of the agreement may result in loss of treatment at the office.

Ohio law versus institutional policy

When opioid treatment falls within Ohio’s 80-MED rule, the agreement must address screening, pill counts/compliance, one opioid prescriber, and tapering. Community Health Services’ 24-hour testing deadline, missed-test interpretation, appointment-for-refill rule, one-pharmacy requirement, and broad loss-of-treatment language are institutional terms rather than statewide wording.

Version status

The document is institution-hosted and marked revised May 2021. Because current distribution of this exact copy has not been established, the page describes it as public institutional evidence rather than a confirmed 2026 form.

Primary sources

← Ohio Contract-for-Care Evidence Library

Reviewed: October 4, 2026.

Evidence boundary: Public hosting establishes the document’s existence, not that this May 2021 version is presently issued to every Community Health Services patient.