"Special Authorization Request Form - Methadone Maintenance Treatment: Daily Dispensing" - Newfoundland and Labrador, Canada

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SPECIAL AUTHORIZATION REQUEST FORM
The Newfoundland and Labrador Prescription Drug Program (NLPDP)
Methadone Maintenance Treatment: Daily Dispensing
Pharmaceutical Services
Department of Health and Community Services
Phone:
(709) 729-6507
P.O. Box 8700, Confederation Bldg.
Toll Free Line:
1-888-222-0533
St. John’s, NL A1B 4J6
Fax:
(709) 729-2851
Patient Information
Patient Name
Date of Birth
NLPDP Drug Card/MCP Number
Address
This form must be completed by Methadone Prescriber
Coverage will be for dispensing Methadone on a daily basis under the supervision of a healthcare professional
for a minimum of two months after treatment initiation and until take-home dose coverage is requested by the
Methadone prescriber when the patient is clinically stable and able to safely store take-home doses.
List of drug(s) of addiction:____________________________________________________________
Has Physician-Patient Treatment agreement been signed? Yes:________
No:__________
Treatment Requested
Methadone Oral Solution
Initiation Date (dd-mm-yyyy)
Additional Comments
Methadone Prescriber Information / Requested By:
Prescriber Name:
(please print)
License Number:
Address:
Phone Number:
Fax Number:
Signature:
Date:
Pharmacist Name:
Pharmacy Name:
(optional)
(optional)
Version December 2016 – Replaces previous forms
SPECIAL AUTHORIZATION REQUEST FORM
The Newfoundland and Labrador Prescription Drug Program (NLPDP)
Methadone Maintenance Treatment: Daily Dispensing
Pharmaceutical Services
Department of Health and Community Services
Phone:
(709) 729-6507
P.O. Box 8700, Confederation Bldg.
Toll Free Line:
1-888-222-0533
St. John’s, NL A1B 4J6
Fax:
(709) 729-2851
Patient Information
Patient Name
Date of Birth
NLPDP Drug Card/MCP Number
Address
This form must be completed by Methadone Prescriber
Coverage will be for dispensing Methadone on a daily basis under the supervision of a healthcare professional
for a minimum of two months after treatment initiation and until take-home dose coverage is requested by the
Methadone prescriber when the patient is clinically stable and able to safely store take-home doses.
List of drug(s) of addiction:____________________________________________________________
Has Physician-Patient Treatment agreement been signed? Yes:________
No:__________
Treatment Requested
Methadone Oral Solution
Initiation Date (dd-mm-yyyy)
Additional Comments
Methadone Prescriber Information / Requested By:
Prescriber Name:
(please print)
License Number:
Address:
Phone Number:
Fax Number:
Signature:
Date:
Pharmacist Name:
Pharmacy Name:
(optional)
(optional)
Version December 2016 – Replaces previous forms
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