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pdfException Request and Record of Justification Under 42 CFR § 8.11 (h)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Page 1 of 2
Form Approved: OMB Number 0930-0206
Expiration Date: 09/30/2006
SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION
CENTER FOR SUBSTANCE ABUSE TREATMENT
See OMB Statement Statement on Reverse
Date of Submission:
3/3/2010 2:04:35 PM
Note: This form was created to assist in the interagency review of patient exceptions in opioid treatment programs (OTPs) under 42
CFR § 8.11 (h).
Exception Request and Record of Justification
Under 42 CFR § 8.11 (h)
Detailed INSTRUCTIONS are on the cover page of this form. PLEASE complete ALL applicable items on this form. Your
cooperation will result in a speedy reply. Thank you.
Program OTP No: WV10012M
(Same as FDA ID)
Program Name:
Telephone:
Patient ID No: 1795
Clarksburg Treatment Center
(304) 622-7511
Fax: (304) 622-7885
E-mail: [email protected]
Name & Title of Requestor: Lee Ann Jones Counselor
Patient's Admission Date: 10/12/2009 Patient's Current Dosage Level:
10mg
Methadone
LAAM
Buprenorphine
Other
Patient's program attendance schedule per week:
(Check next to all the days that the patient attends*)
S
M
T
W
T
F
S
*If current attendance is less than once per week, please enter schedule:
Patient's Status:
Homemaker
Employed
Student
Disabled
Other
Nature of Request:
Temporary take-home medication
Temporary change in protocol
Detoxification exception
Other:
Decrease regular attendance to
(Place an "X" next to the appropriate days*):
S
M
T
W
T
F
S
Beginning date: 3/12/2010
*If new attendance is less than once per week, please enter schedule:
Dates of Exception:
From:
3/12/2010
To:
3/21/2010
# of doses needed:
9
Justification:
Family Emergency
Incarceration
Funeral
Vacation
Transportation Hardship
Step/Level Change
Employment
Medical
Long-Term Care Facility
Other Residential Treatment
Homebound
Split Dose
Other: Pt is traveling out of town for vacation and there is no guest dosing available within 100 miles for suboxone. Pt is
counseling compliant. UDS results 12/21/09; 1/12/10; 2/16/10 - all licit.
Regulation Requirements:
For take-home medication: Has the patient been informed of
the dangers of children ingesting methadone or LAAM?
For take-home medication: Has the program physician
Yes
No
N/A
determined that the patient meets the 8-point evaluation criteria to
determine whether the patient is responsible enough to handle
methadone as outlined in 42 CFR §8.12(i)(2)(i)-(viii)?
For multiple detoxification admissions: Did the physician
Yes
No
N/A
justify more than 2 detoxification episodes per year and assess the
patient for other forms of treatment (include dates of detoxification
episodes) as required by 42 CFR §8.12(e)(4)?
No
Yes
N/A
Comments:
Pt is traveling out of town for vacation and there is no guest dosing available within 100 miles for suboxone. Pt is counseling
https://otp-extranet.samhsa.gov/Patient/ExceptionRequest.aspx?Source=VTJGdGFITmgtZEdXOGZHQ0t...
3/3/2010
Exception Request and Record of Justification Under 42 CFR § 8.11 (h)
Page 2 of 2
compliant. UDS results 12/21/09; 1/12/10; 2/16/10 - all licit.
Submitted By:
Cindy Dugan
Electronically signed by Cindy Dugan
3/3/2010 2:04:35 PM EST
Printed Name of Physician
Signature of Physician
Date
State Response to Request:
Approved
Denied
State Opioid Treatment Authority
Date
Decision not required
Federal Response to Request:
Approved
Denied
Decision not required
Electronically signed by Elsworth Dory
3/3/2010 2:25:18 PM EST
Public Health Advisor, Center for Substance
Abuse Treatment
Date
This exception is contingent upon approval by your State Opioid Treatment Authority (as applicable) and may not be implemented until
you receive such approval.
Purpose of Form: This form was created to facilitate the submission and review of patient exceptions under 42 CFR § 8.11(h). This does
not preclude other forms of notification.
Paperwork Reduction Act Statement
Public reporting burden for this collection of information is estimated to average 25 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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 (0930-0206); Suite 7-1043, 1 Choke Cherry Road, Rockville, MD 20857. 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 0930-0206.
https://otp-extranet.samhsa.gov/Patient/ExceptionRequest.aspx?Source=VTJGdGFITmgtZEdXOGZHQ0t...
3/3/2010
| File Type | application/pdf |
| File Title | https://otp-extranet.samhsa.gov/Patient/ExceptionRequest.aspx?S |
| Author | NREUTER |
| File Modified | 2010-03-03 |
| File Created | 2010-03-03 |