Get Form Sma 168 Printable

The Form SMA 168 is an essential document designed to facilitate the submission and review of patient exception requests under 42 CFR § 8.11(h). This guide will provide you with clear, step-by-step instructions to assist you in accurately completing the form online.

Follow the steps to successfully complete the Form SMA 168 Printable online:

1. Press the ‘Get Form’ button to access the Form SMA 168 and open it in the editor.
2. Enter the program OTP number, ensuring it follows the required format, which consists of two letters representing your State abbreviation, followed by five digits, and ending with a letter.
3. Fill in the confidential patient ID number without using any identifying information such as the patient's name.
4. Provide the name of the opioid treatment program, clinic, or hospital where the patient is enrolled.
5. Include a voice telephone number and fax number with area codes.
6. Indicate the email address of the contact person associated with this request.
7. Enter the name and title of the requestor, typically the physician or authorized staff member.
8. Document the patient's admission date to the facility.
9. Fill in the patient’s current dosage level of medication in milligrams (mg).
10. Mark the appropriate medication type that the patient is currently taking (, LAAM, or Other). If 'Other' is selected, specify the medication name.
11. Confirm the patient's program attendance schedule by marking the days of the week when the patient currently reports to the clinic.
12. Indicate the patient's status by placing an 'X' in the appropriate box that describes them (e.g., employed, unemployed, etc.).
13. For the request for change, select the nature of the request by marking an 'X' on the line that best describes your request.
14. Indicate the beginning date for the new attendance schedule.
15. If applicable, provide the dates for the requested exception period.
16. Specify how many doses are needed during the exception period.
17. Mark the justification for the request, placing an 'X' next to the reason that applies or selecting 'Other' to specify.
18. Review the regulation requirements and indicate compliance by marking 'Yes', 'No', or 'N/A' as appropriate.
19. Print the name of the physician making the request and obtain their signature.
20. Enter the date of the physician’s signature.
21. Once all information is completed, save the changes, and choose to download, print, or share the form as needed.

Proceed to complete your documents online to ensure a smooth submission process.