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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
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Note: Notification is required by Sec. 303(g)(2), Controlled Substances Act (21 USC § 823(g)(2)). See instructions below. | |
Please send copies of supporting documents, such as training certificates with your name and DEA Registration Number to: Substance Abuse and Mental Health Services AdministrationDivision 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. Return to Form |
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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. Return to Form | 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. Return to Form |
6. Group practice is defined under § 1877(h)(4) of the Social Security Act. Return to Form | 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. Return to Form |
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. Return to Form | |
About CSAT Buprenorphine e-mail discussion list: CSAT is developing an e-mail discussion list that would allow practitioners to ask questions or raise issues about partial opioid agonist treatment. The list administrator would refer questions to CSAT staff or other experts. Members of the list would be able to submit their own responses. List subscribers would receive copies of all messages on a periodic basis, depending on the volume of traffic. If you click the box on the waiver notification form to join this list, you will be notified by e-mail when the list is activated. You must also complete item 5 on the waiver form (e-mail address). | |
About Buprenorphine in my e-mail: CSAT is compiling a list of practitioners who wish to receive information by e-mail about buprenorphine and other approved partial opioid agonists. If you click the box on the waiver notification form, CSAT will send you e-mails that may contain important new information or may tell you where to find details by mail or telephone, or on a Web site. Your e-mail address will not be furnished to any pharmaceutical firm or any other outside party, and will not be used by CSAT for any purposes other than to notify you about new developments in partial opioid agonist treatment. New information might include changes in waiver requirements, approval of new drugs, or adverse actions on previously approved drugs. To receive information by e-mail, you must complete item 5 on the waiver form (E-mail address). | |
Authority: Section 303
of the Controlled Substances Act of 1970 (21 U.S.C. §823(g)(2)).
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. 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