Get Pdf Version Of The Waiver Form - - Samhsa - Samhsa

This guide provides a comprehensive overview of how to correctly fill out the PDF Version of the Waiver Form from SAMHSA. Following these instructions will ensure that your submission is complete and accurate, which is essential for compliance and approval.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the Waiver Form and open it in the editor.
2. Fill in your name as the practitioner in item 1a. Ensure that you provide your state medical license number in item 1b and your DEA registration number in item 1c.
3. Enter the address of your primary location in item 2, including the zip code. This must match the address on your DEA registration.
4. Provide your telephone number, including area code, in item 3, and your fax number in item 4, both of which are essential for communication.
5. Include your email address in item 5, as it is required for submission and waiver receipt. Make sure it is valid and correctly formatted.
6. Indicate the purpose of your notification in item 6 by checking the appropriate box for new notification or second notification based on your situation.
7. In item 7, certify your intention to use only FDA-approved narcotic drugs by checking the corresponding box.
8. In item 8, confirm that you meet at least one qualifying criterion by checking each box that applies and attaching the necessary documentation if required.
9. Complete item 9 by certifying your capacity to refer patients for appropriate counseling services by checking the box.
10. In item 10, indicate your maximum patient load by certifying either up to 30 patients or up to 100 patients for second notifications.
11. In item 11, consent or do not consent to the release of your information to the SAMHSA Locator Website by marking the respective box.
12. Finally, review and sign the form in item 12, including the date of submission. Ensure that all information is true and accurate to avoid potential penalties.
13. Once completed, save your changes, download, print, or share the form as necessary.

Start filling out your forms online today for efficient processing.