Get Notification Of Intent To Use Schedule Ii Iv Or V Opioid Drugs For Maintenance And Detoxification

Filling out the Notification Of Intent To Use Schedule II, IV, or V Opioid Drugs For Maintenance And Detoxification form is a crucial step for practitioners intending to treat patients with opioid addiction. This guide provides a step-by-step approach to ensure a smooth and accurate submission process online.

Follow the steps to complete the form accurately online.

1. Click the ‘Get Form’ button to access the form online and open it in your preferred document management tool.
2. Fill in the 'Date of Submission' field at the top of the form to indicate when you are filing the form.
3. In section 1a, enter your name as the practitioner. Complete section 1b with your state medical license number and section 1c with your DEA registration number.
4. Provide your primary practice address in section 2, ensuring to include the ZIP code for accurate correspondence.
5. Input your telephone number in section 3 and, if applicable, your fax number in section 4. You may also add your email address in section 5, but it is optional.
6. Indicate the purpose of your notification in section 6 by selecting one of the options, such as 'New Notification' or 'Second Notification of need and intent to treat up to 100 patients'.
7. In section 7, check the box to certify that you will only use approved Schedule III, IV, or V drugs for maintenance or detoxification treatment.
8. Complete section 8 by confirming your qualifications. Check all that apply, and ensure to provide any necessary documentation for the training or certification listed.
9. In section 9, certify your capacity to refer patients to appropriate counseling and other ancillary services.
10. In section 10, certify that you will not exceed the specified maximum patient load for maintenance or detoxification treatment.
11. In section 11, indicate whether you consent to the release of your information to the SAMHSA Physician and Treatment Program Locator website.
12. Finally, in section 12, sign and date the form, certifying that all information provided is true to your knowledge.
13. After completing the form, review all entries for accuracy. Save changes, and choose to download, print, or share the completed form as required.

Ensure your submission is complete and accurate by following these steps to fill out the form online.