Waiver Notification Form

Notification of Intent to Use Schedule III, IV, or V Opioid Drugs
for the Maintenance and Detoxification Treatment
of Opiate Addiction under 21 USC § 823(g)(2)

Form Approved: 0930-0234
Expiration Date: 12/31/2005
See OMB Statement at bottom

DATE OF SUBMISSION

Note: Notification is required by Sec. 303(g)(2), Controlled Substances Act (21 USC § 823(g)(2)).

1a. NAME OF PRACTITIONER

b. State Medical License Number	c. DEA Registration Number
Licensing State: License Number:

2. ADDRESS OF PRIMARY LOCATION (Include Zip Code)

3. TELEPHONE NUMBER (Include Area Code)

4. FAX NUMBER (Include Area Code)

5. EMAIL ADDRESS (Optional)

6. NAME AND ADDRESS OF GROUP PRACTICE

7. GROUP PRACTICE EMPLOYER IDENTIFICATION NUMBER

8. PURPOSE OF NOTIFICATION (Check all that apply)

New

Immediate

9. GROUP PRACTITIONERS

Name	DEA Registration Number

10. CERTIFICATION OF USE OF NARCOTIC DRUGS UNDER THIS NOTIFICATION
I certify that I will only use schedule III, IV, or V drugs or combinations of drugs that have been approved by the FDA for use in maintenance or detoxification treatment and that have not been the subject of an adverse determination.

11. CERTIFICATION OF QUALIFYING CRITERIA (Check each appropriate source and provide documentation.) I certify that I meet at least one of the following criteria and am therefore a qualifying physician (check and provide documentation for all that apply):

Subspecialty board certification in addiction psychiatry from the American Board of Medical Specialties
Addiction certification from the American Society of Addiction Medicine
Subspecialty board certification in addiction medicine from the American Osteopathic Association
Completion of not less than eight hours of training for the treatment and management of opiate-dependent patients provided by the following organization(s):
- American Society of Addiction Medicine
- American Academy of Addiction Psychiatry
- American Medical Association
- American Osteopathic Association
- American Psychiatric Association
- Other (specify)
- Date and location of training (Use "Web" for city if web training was received):
  On in
Participation as an investigator in one or more clinical trials leading to the approval of a schedule III, IV, or V narcotic drug for maintenance or detoxification treatment
State medical licensing board-approved experience or training in the treatment and management of opiate-dependent patients.
OTHER (Specify)

12. CERTIFICATION OF CAPACITY

I certify that I have the capacity to refer patients for appropriate counseling and other appropriate ancillary services.

13. CERTIFICATION OF MAXIMUM PATIENT LOAD
    I certify that I or my group practice will not exceed 30 patients for maintenance or detoxification treatment at one time.

14. CONSENT TO RELEASE IDENTIFYING INFORMATION TO SAMHSA BUPRENORPHINE PHYSICIAN LOCATOR WEB SITE
    I consent to the release of my name, address, and phone number to the SAMHSA Buprenorphine Physician Locator Web site.
    I do not consent to the release of my name, address, and phone number to the SAMHSA Buprenorphine Physician Locator Web site.
(Read instruction 14 below before answering)

15. I certify that the information presented above is true and correct to the best of my knowledge. I certify that I will notify SAMHSA at the address below if any of the information contained on this form changes.
Note: Any false, fictitious, or fraudulent statements or information presented above or misrepresentations relative thereto may violate Federal laws and could subject you to prosecution, and/or monetary penalties, and or denial, revocation, or suspension of DEA registration. (See 18 USC § 1001; 31 USC §§ 3801-3812; 21 USC § 824.)



Signature Date

Please send the completed form to:

Substance Abuse and Mental Health Services Administration
Division of Pharmacologic Therapies
Attention: Opioid Treatment Waiver Program
1 Choke Cherry Road, Rm. 2-1063
Rockville, MD 20857
Fax 240-276-1630
Phone 240-276-2716

This form is intended to facilitate the implementation of the provisions of 21 USC § 823 (g)(2). The Secretary of DHHS will use the information provided to determine whether practitioners meet the qualifications for waivers from the separate registration requirements under the Controlled Substances Act (21 USC § 823 (g)(1)). The Drug Enforcement Administration will assign an identification number to qualifying practitioners and the number will be included in the practitioner's registration under 21 USC § 823 (f).
This form may be completed and submitted electronically (including facsimile) to facilitate processing.

1. The practitioner must identify the DEA registration number issued under 21 USC§ 823(f) to prescribe substances controlled in Schedules III, IV, or V. 2. The address should be the primary address listed in the practitioner's registration under § 823(f). Only one address should be specified. If the narcotic drugs or combinations to be used under this notification are to be dispensed by the practitioner then the address must reflect the site where the medication will be dispensed.

6. Group practice is defined under § 1877(h)(4) of the Social Security Act. 8. Purpose of notification:
New - an initial notification for a waiver submitted for the purpose of obtaining an identification number from DEA for inclusion in the registration under 21 U.S.C. §823(f).

Immediate - a notification submitted for the purpose of notifying the Secretary and the Attorney General of the intent to immediately facilitate the treatment of an individual (one) patient.

Note: It is permissible to submit a new and immediate notification simultaneously.

14. The SAMHSA Buprenorphine Physician Locator Web site is publicly accessible at http://buprenorphine.samhsa.gov/bwns_locator/. The Locator Web site lists the names and practice contact information of physicians with DATA waivers who agree to be listed on the site. The Locator Web site is used by the treatment-seeking public and health care professionals to find physicians with DATA waivers. The Locator Web site additionally provides links to many other sources of information on substance abuse. No physician listings on the SAMHSA Buprenorphine Physician Locator Web site will be made without the express consent of the physician.

PRIVACY ACT INFORMATION
Authority: Section 303 of the Controlled Substances Act of 1970 (21 U.S.C. §823(g)(2)).
Purpose: To obtain information required to determine whether a practitioner meets the requirements of 21 U.S.C. §823(g)(2).
Routine Uses: Disclosures of information from this system are made to the following categories of users for the purposes stated:
A. Medical specialty societies to verify practitioner qualifications.
B. Other federal law enforcement and regulatory agencies for law enforcement and regulatory purposes.
C. State and local law enforcement and regulatory agencies for law enforcement and regulatory purposes.
D. Persons registered under the Controlled Substance Act (PL 91-513) for the purpose of verifying the registration of customers and practitioners.

Effect: This form was created to facilitate the submission and review of waivers under 21 U.S.C. §823(g)(2). This does not preclude other forms of notification.

Paperwork Reduction Act Statement

Public reporting burden for completing this form is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the completed form. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0234).

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to SAMHSA Reports Clearance Officer; Paperwork Reduction Project (0930-0234); Room 16-105, Parklawn Building; 5600 Fishers Lane, Rockville, MD 20857.

SMA-167