"Methadone Take-Home Bottles Chain-Of-Custody Record Form" - Connecticut

Methadone Take-Home Bottles Chain-Of-Custody Record Form is a legal document that was released by the Connecticut Department of Mental Health & Addiction Services - a government authority operating within Connecticut.

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STATE OF CONNECTICUT
DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES
A Healthcare Service Agency
DANNEL P. MALLOY
MIRIAM E. DELPHIN-RITTMON, PH.D.
GOVERNOR
COMMISSIONER
Methadone Take-Home Bottles
Chain-Of-Custody Record
Today’s Date: __________________________
Name of Program Delivering Methadone: ________________________________________
Initials of Client: _______________________
ID Number: _______________________
Reason for Chain of Custody:___________________________________________________
____________________________________________________________________________
Client’s Daily Dosage: ____________________________________
Number of doses/bottles being delivered: _____________________
Date(s) of Delivery: _______________________________________
Additional Comments: ________________________________________________________
____________________________________________________________________________
______________________________________________
______________________
Signature of individual delivering take-home bottle(s)
Date
…………………………………………………………………………………………………….
Name of Program/Individual Receiving Methadone: _______________________________
Relation to client: ____________________________________________________________
Date Methadone delivered and received: _________________________________________
Signature of individual receiving take-home bottle(s)
Date
(860) 418-7000
410 Capitol Avenue, P.O. Box 341431, Hartford, Connecticut 06134
www.ct.gov/dmhas
STATE OF CONNECTICUT
DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES
A Healthcare Service Agency
DANNEL P. MALLOY
MIRIAM E. DELPHIN-RITTMON, PH.D.
GOVERNOR
COMMISSIONER
Methadone Take-Home Bottles
Chain-Of-Custody Record
Today’s Date: __________________________
Name of Program Delivering Methadone: ________________________________________
Initials of Client: _______________________
ID Number: _______________________
Reason for Chain of Custody:___________________________________________________
____________________________________________________________________________
Client’s Daily Dosage: ____________________________________
Number of doses/bottles being delivered: _____________________
Date(s) of Delivery: _______________________________________
Additional Comments: ________________________________________________________
____________________________________________________________________________
______________________________________________
______________________
Signature of individual delivering take-home bottle(s)
Date
…………………………………………………………………………………………………….
Name of Program/Individual Receiving Methadone: _______________________________
Relation to client: ____________________________________________________________
Date Methadone delivered and received: _________________________________________
Signature of individual receiving take-home bottle(s)
Date
(860) 418-7000
410 Capitol Avenue, P.O. Box 341431, Hartford, Connecticut 06134
www.ct.gov/dmhas