Patient Notice

Notification of Intent to Use Schedule III, IV, or V Opioid Drugs for the Maintenance and Detoxification Treatment of Opiate Addiction

OMB: 0930-0234

IC ID: 222816

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Patient Notice
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction Patient Notice Patient Notice Attachment C - Patient Notice.docx Yes Yes Fillable Fileable

Health Public Health Monitoring

 

1 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1 0 -51 0 0 52
Annual IC Time Burden (Hours) 3 0 0 0 0 3
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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