Form SMA-162

DEPARTMENT OF HEALTH AND HUMAN SERVICES
SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION
CENTER FOR SUBSTANCE ABUSE TREATMENT

Application for Certification to Use Opioid Drugs
in a Treatment Program Under 42 CFR § 8.11

Form Approved: OMB Number XXXX-XXXX

Expiration Date: xx/xx/xxxx

See OMB Statement on Reverse

DATE OF SUBMISSION

Note: This form is required by 42 CFR 8.11 pursuant to Sec. 303, Controlled Substances Act (21 USC § 823) and the Drug Abuse Prevention and
Control Act of 1970 (42 USC § 275(a)). Failure to report may result in a recommendation for the suspension or revocation of the opioid
treatment program registration.

1a. Name of Program: (Name of primary dispensing location)

1d. DEA Registration Number:

1b. Doing business as:

1e. ISATS-ID: (e.g., AL100002)

1c. Opioid Treatment Program Number: (e.g., AL-10001-M)

1f. National Provider Identification Number: (e.g., 1234567890)

2. Address of Primary Dispensing Location: (Include ZIP Code)

3. Telephone Number: (Include Area Code)

4. E-Mail Address:

5. Name and Address of Program Sponsor: (Include ZIP Code)

6. Telephone Number: (Include Area Code)

7. E-Mail Address:

8. Name of Medical Director: (and Address—if different than Dispensing Location, above)

9. DEA Registration Number:

10. Telephone Number: (Include Area Code)

11. E-Mail Address:

12. Purpose of Application*:

□ Provisional Certification □ Renewal/Re-certification □ New Sponsor □ New Medical Director □ Relocation □ Medication Unit

13a. Treatment Type (Check each appropriate treatment.) 13b. Number of patients treated by each drug) on date of submission

□ Methadone	________________________________________________
□ Buprenorphine	________________________________________________
□ Naltrexone	_________________________________________________
□ Other (Specify)	_________________________________________________

Treatment type	Number of patients in treatment on date of submission
Methadone
Buprenorphine
Naltrexone
Other (please specify)

14a. Program Status:

□ For-profit

□ Nonprofit

□ Public/Government

□ VA

□ Other (Specify) _____________________________

14b. Program Funding Sources: (Check each appropriate agency and attach the address of each, if applicable.)

□ SAMHSA (Block Grant)

□ Private Charities

□ Department of Veterans Affairs

□ Patient Payment

□ State Government

□ County Government

□ Indian Health Service

□ Private Health Insurance

□ Other (Specify) _____________________________

Program Sponsor: (Signature)

Date:

FORM SMA-162 (revised 2019) (FRONT)

*The preferred method for submitting this form to CSAT/DPT for a provisional certification is on the MAT Web site which contains complete instructions for preparing and submitting your request, http://dpt2.samhsa.gov/sma162 . Submission of the SMA-162 for provisional certification and other purposes named in item #12 above are described here: http://www.samhsa.gov/medication-assisted-treatment/opioid-treatment-programs/apply. It is highly encouraged that submission take place in this capacity.  If you are unable to submit online, the form may be e-mailed as an attachment to your compliance officer whose contact information can be found at http://www.samhsa.gov/medication-assisted-treatment/opioid-treatment-programs/compliance-officers, or sent by traditional mail (include copies of all attachments) to the mailing address below. Additional information can be found on the MAT webpage, http://www.samhsa.gov/medication-assisted-treatment.

Center for Substance Abuse Treatment

Division of Pharmacologic Therapies

Substance Abuse and Mental Health Services Administration

Attention: OTP Certification Program5600 Fishers Lane

Rockville, MD 20857

Paperwork Reduction Act Statement

Public reporting burden for this collection of information is estimated to average between 6 minutes and 1 hour 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 (XXXX-XXXX); 5600 Fishers Lane, 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 XXXX-XXXX.

FORM SMA-162 (revised 2019) (BACK)