DEPARTMENT
OF HEALTH AND HUMAN SERVICES
Application
for Certification to Use Opioid Drugs |
Form Approved: OMB Number XXXX-XXXX Expiration Date: xx/xx/xxxx See OMB Statement on Reverse |
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DATE OF SUBMISSION |
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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 |
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1a. Name of Program or Name Change: (Name of primary dispensing location) |
1d. DEA Registration Number: |
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1b. Doing business as: |
1e. ISATS-ID: (e.g., AL100002) |
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1c. Opioid Treatment Program Number: (e.g., AL-10001-M) |
1f. National Provider Identification Number: (e.g., 1234567890) |
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2. Address of Primary Dispensing Location: (Include ZIP Code) |
3. Telephone Number: (Include Area Code) 4. E-Mail Address: |
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5. Name and Address of Program Sponsor: (Include ZIP Code) |
6. Telephone Number: (Include Area Code) 7. E-Mail Address: |
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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: |
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12. Purpose of Application*: |
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□ Provisional Certification □ Renewal/Re-certification □ New Sponsor □ New Medical Director □ Relocation □ Medication Unit |
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13a. Treatment Type (Check each appropriate treatment.) 13b. Number of patients treated with each drug on date of submission
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14a. Program Status: |
□ For-profit |
□ Nonprofit |
□ Public/Government |
□ VA |
□ Other (Specify) _____________________________ |
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14b. Program Funding Sources: (Check each appropriate agency and attach the address of each, if applicable.) |
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□ SAMHSA (Block Grant) |
□ Private Charities |
□ Department of Veterans Affairs |
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□ Patient Payment |
□ State Government |
□ County Government |
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□ Indian Health Service |
□ Private Health Insurance |
□ Other (Specify) _____________________________ |
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Program Sponsor: (Signature) |
Date: |
FORM SMA-162 (revised 2021) (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 2021) (BACK)
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |