Get Sma-167 - Samhsa

The SMA-167 form is an essential document for practitioners intending to use Schedule III, IV, or V opioid drugs for the maintenance and detoxification treatment of opiate addiction. This guide will provide clear, step-by-step instructions on how to fill out the form effectively and submit it online.

Follow the steps to fill out the SMA-167 form accurately.

1. Press the ‘Get Form’ button to access the SMA-167 document online. This action allows you to retrieve the form and start filling it out in your preferred editor.
2. In section 1a, enter the name of the practitioner. Ensure that the name matches the one associated with your medical license. In item 1b, provide your State Medical License Number, and in item 1c, include your DEA Registration Number.
3. Section 2 requires you to input the address of your primary location, including the zip code. This should match the address listed in your DEA registration.
4. Enter your telephone number in section 3, including the area code. For section 4, provide your fax number, also including the area code.
5. In section 5, input a valid email address, as this is a required field that will allow for further communication.
6. In section 6, specify the purpose of the notification by selecting the appropriate option: a new notification, a new notification with intent to treat an individual patient, or a second notification for treating up to 100 patients.
7. For sections 7 and 8, certify that you will use only approved Schedule III, IV, or V drugs, and confirm that you meet at least one of the qualifying criteria by checking the appropriate boxes and providing any necessary documentation.
8. Section 9 asks you to certify that you can refer patients for appropriate counseling and ancillary services. Ensure to fill this out accurately.
9. In section 10, state your maximum patient load. Affirm that you will not exceed 30 patients at one time or certify that you need to treat up to 100 patients for a second notification.
10. Section 11 involves consent to release your identifying information to the SAMHSA Physician and Treatment Program Locator website. Choose your preference.
11. In section 12, certify that all provided information is accurate by signing and dating the form.
12. After completing the form, save your changes. You have the option to download, print, or share the form as needed.

Complete your SMA-167 form online today to ensure compliance and facilitate the treatment process.