Form Request for Patien Request for Patien Request for Patient Limit Increase

Request For Patient Limit Increase

SMA-### Form Approved: 0000-0000
Date: 0#/##/201#
See OMB Statement Below
DATE OF SUBMISSION

Under 42 C.F.R. 8.620
To Complete Online Go To: http://buprenorphine.samhsa.gov/pls/bwns/waiver

See instructions on reverse.
PLEASE DON’T FORGET TO SIGN AND DATE THIS FORM (ITEM 9)

1A. NAME OF PRACTITIONER

1B. State Medical License Number

1C. Specialty

2. ADDRESS OF SERVICE LOCATION (Include Zip Code) (See instruction below)

1D. DEA Registration Number

3. TELEPHONE NUMBER (Include Area Code)

4. FAX NUMBER (Include Area Code)

2A. Is this location a FQHC? Yes

No

5. EMAIL ADDRESS (Required)

6. PURPOSE OF NOTIFICATION
.

New Notification

Renewal Notification

Emergency Situation Notification

7A. PLEASE ANSWER THE FOLLOWING FOR INCREASE TO 275 PATIENTS
7A1. I certify that I meet at least one of the following criteria and am therefore a qualifying practitioner (Check and provide copies of documentation
that apply):
I certify that I meet all the requirements to treat up to 275 patients as specified in 42 CFR 8.610(a) and (b)(1) as a
practitioner with additional credentialing in addiction psychiatry or addiction medicine.
OR
I certify that I meet the qualifying criteria and have the capacity to meet all the requirements to treat up to 275 patients as
specified in 42 CFR 8.610(a) and (b)(1) in a Qualified Practice Setting.
7A2.

I intend to treat up to 275 patients and I certify that I will not exceed 275 for maintenance or detoxification treatment at one time.

7A3.

I certify that I will adhere to nationally recognized evidence-based guidelines for the treatment of patients with opioid use disorders.

7A4.

I certify that I will provide patients with necessary behavioral health services as defined in § 8.2 or through an established formal
agreement with another entity to provide behavioral health services.

7A5.

I certify that I will provide appropriate releases of information, in accordance with Federal and State laws and regulations, including the
Health Information Portability and Accountability Act Privacy Rule and part 2 of this chapter, if applicable, to permit the coordination of
care with behavioral health, medical, and other service practitioners.

7A6.

I certify that I will use patient data to inform the improvement of outcomes.

7A7.

I certify that I will adhere to a diversion control plan to manage the covered medications and reduce the possibility of diversion of
covered medications from legitimate treatment use.

7A8.

I certify that I have considered how to assure continuous access to care in the event of practitioner incapacity or an emergency
situation that would impact a patient’s access to care as defined in § 8.2.

7A9.

I certify that I will notify all patients above the 100 patient level, in the event that the request for the higher patient limit is not renewed
or is denied, that the practitioner will no longer be able to provide MAT services using buprenorphine to them and make every effort
to transfer patients to other addiction treatment.

REVISED: 3/21/16

7B. PLEASE ANSWER THE FOLLOWING TO REQUEST AN EMERGENCY INCREASE TO 275 PATIENTS
7B1.

I certify that I am practicing in an emergency situation as defined in 42 CFR 8.2 and 8.655 (documentation attached).

7B2.

I understand that I may not exceed my current limit until notified by SAMHSA.

7B3.

I certify that, once approved for the higher limit, I will not exceed 275 patients for maintenance or detoxification treatment at one time.

7B4.

I understand that once approved for the higher limit, I may only practice at the higher limit for a period not to exceed six months unless
such approval is extended under 42 CFR 8.655(d).

8. 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.
9. CONSENT (Read instruction 9 below before answering)
I consent to the release of my name, primary address, and phone number to the SAMHSA Treatment Locator web site.
I do not consent to the release of my name, primary address, and phone number to the SAMHSA Treatment Locator web site.

10. 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.)

X__________________________________
Signature
Substance Abuse and Mental Health Services Administration,
Division of Pharmacologic Therapies
Please submit form electronically at:
http://buprenorphine.samhsa.gov/pls/bwns/waiver
Or Fax To: 240-238-9858
ATTN: BUPE WAIVER
For questions, please call
1-866-287-2728 (1-866-BUP-CSAT)
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.

X ________________________
Date

This form is intended to facilitate the implementation of the provisions of 21
USC § 823(g)(2) and 42 CFR § 8.620. The Secretary of HHS will use the
information provided to determine whether practitioners meet the qualifications
for a waiver to increase their patient limit to 275 separate from the registrations
requirements under the Controlled Substances Act (21 USC § 823(g)(1)). This
form may be completed and submitted electronically (including facsimile) to
facilitate processing.
2. Only one address should be specified. For the practitioner to dispense the narcotic drugs or
combinations to be used under this notification, the primary address listed here must be the same
primary address listed in the practitioner's registration under § 823(f).

6. Purpose of notification: Increase to 275 Notification - For practitioners who submitted a notification to treat up to 100 patients at least one year ago and meet
the additional qualifying criteria or have a documented emergency situation and intend to treat up to 275 patients.
9. The SAMHSA Buprenorphine Treatment Locator web site is publicly accessible at http://buprenorphine.samhsa.gov/bwns_locator/. The Locator Web site lists
the names and most recent practice contact information of practitioners 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 practitioners with DATA waivers. The Locator Web site additionally provides links to many
other sources of information on substance use disorder treatment. No practitioner listings on the SAMHSA Buprenorphine Treatment Locator web site will be
made without the express consent of the practitioner.
Paperwork Reduction Act Statement
Privacy Act Information
Authority: Section 303 of the Controlled Substances Act of 1970 (21 USC § 823(g)(2)). Purpose:
To obtain information required to determine whether a practitioner meets the requirements of
21 USC § 823(g)(2).Routine Uses: Disclosures of information from this system are made to the
following categories of users for the purposes stated:

REVISED: 3/21/16

Public reporting burden for completing this form is
estimated to average 60 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

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 USC § 823(g)(2). This does not preclude other forms of notification.

REVISED: 3/21/16

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 XXXX-XXXX. 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 (XXXXXXXX); Room X-XXXX, 5600 Fishers Lane,
Rockville, MD 20857