Notice of Intent

Notification of Intent to Use Schedule III, IV, or V Opioid Drugs
for the Maintenance and Detoxification Treatment
of Opiate Addiction under 21 USC § 823(g)(2)

Form Approved: 0930-0234
Date: 07/31/2018
See OMB Statement on Reverse
DATE OF SUBMISSION

Note: Notification is required by § 303(g)(2), Controled Substances Act (21 USC § 823(g)(2)). See instructions on reverse.
For second notifications, you must complete items 6, 8, 9, 10, and sign and date the form (item 12).
1a. NAME OF PRACTITIONER

b. State Medical License Number

c. DEA Registration Number

2. ADDRESS OF PRIMARY LOCATION (Include Zip Code) (See instruction below)

3. TELEPHONE NUMBER (Include Area Code)
4. FAX NUMBER (Include Area Code)
5. EMAIL ADDRESS (Required)

6. PURPOSE OF NOTIFICATION (See instruction below)
New Notification

New Notification, with the intent to immediately facilitate treatment of an individual (one) patient

Second notification of need and intent to treat up to 100 patients

7. CERTIFICATION OF USE OF NARCOTIC DRUGS UNDER THIS NOTIFICATION
I certify that I will only use Schedule III, IV, or V drugs or combinations of drugs that have been approved by the FDA for use in maintenance or detoxification treatment and that have
not been the subject of an adverse determination.

8. CERTIFICATION OF QUALIFYING CRITERIA
I certify that I meet at least one of the following criteria and am therefore a qualifying physician (Check and provide copies of documentation for all that apply):
Subspecialty board certification in addiction psychiatry from the American Board of Medical Specialties
Addiction certification from the American Society of Addiction Medicine
Subspecialty board certification in addiction medicine from the American Osteopathic Association
Completion of not less than eight hours of training for the treatment and management of opioid-dependent patients provided by the following organization(s):
Date and location of training
American Society of Addiction Medicine

__________________________

American Academy of Addiction Psychiatry __________________________
American Medical Association

__________________________

American Osteopathic Association

__________________________

American Psychiatric Association

__________________________

Other (Specify, include date and location)

__________________________

Participation as an investigator in one or more clinical trials leading to the approval of a Schedule III, IV, or V narcotic drug for maintenance or detoxification treatment
State medical licensing board-approved experience or training in the treatment and management of opioid-dependent patients
OTHER (Specify) _______________________

For Second Notifications - I certified qualifications in my initial notification and these qualifications have not changed.
9. CERTIFICATION OF CAPACITY
I certify that I have the capacity to refer patients for appropriate counseling and other appropriate ancillary services.

S MA-167

Page 2

10. CERTIFICATION OF MAXIMUM PATIENT LOAD
I certify that I will not exceed 30 patients for maintenance or detoxification treatment at one time.
Second Notification - I need to treat up to 100 patients and I certify that I will not exceed 100 patients for maintenance or detoxification treatment at one time.

11. CONSENT TO RELEASE IDENTIFYING INFORMATION TO SAMHSA BUPRENORPHINE PHYSICIAN AND TREATMENT PROGRAM LOCATOR WEB SITE
(Read instruction 11 below before answering)
I consent to the release of my name, primary address, and phone number to the SAMHSA Buprenorphine Physician and Treatment Program Locator Web site.
I do not consent to the release of my name, primary address, and phone number to the SAMHSA Buprenorphine Physician and Treatment Program Locator Web site.

12. I certify that the information presented above is true and correct to the best of my knowledge. I certify that I will notify SAMHSA at the address below if any of the
information contained on this form changes. Note: Any false, fictitious, or fraudulent statements or information presented above or misrepresentations relative thereto may
violate Federal laws and could subject you to prosecution, and/or monetary penalties, and or denial, revocation, or suspension of DEA registration. (See 18 USC § 1001; 31 USC
§§ 3801–3812; 21 USC § 824.)
__________________________________
S ignature

________________
Date

Please send the completed form to:
S ubstance Abuse and Mental Health S ervices Administration
Division of Pharmacologic Therapies
Attention: Opioid Treatment Waiver Program
One Choke Cherry Road, Rm 7-1040
Rockville, MD 20857
Fax 240-238-9858
Phone 1-866-287-2728 (1-866-BUP-CS AT)

This form is intended to facilitate the implementation of the provisions of 21 US C § 823(g)(2). The S ecretary of DHHS will use the information provided to determine whether practitioners meet the qualifications for waivers
from the separate registration requirements under the Controlled S ubstances Act (21 US C § 823(g)(1)). The Drug Enforcement Administration will assign an identification number to qualifying practitioners and the number
will be included in the practitioner’s registration under 21 US C § 823(f).
This form may be completed and submitted electronically (including facsimile) to facilitate processing.

1. The practitioner must identify the DEA registration number issued under 21 US C § 823(f) to prescribe
substances controlled in S chedules III, IV, or V.

2. Only one address should be specified. For the practitioner to dispense the narcotic drugs or combinations to
be used under this notification, the primary address listed here must be the same primary address listed in
the practitioner's registration under § 823(f).

6. Purpose of notification:
New Notification - an initial notification for a waiver submitted for the purpose of obtaining an identification number from DEA for inclusion in the registration under 21 US C § 823(f).
New Notification, with the intent to immediately facilitate treatment of an individual (one) patient - an initial notification submitted for the purpose described above, with the additional purpose of notifying the S ecretary and
the Attorney General of the intent to provide immediate opiate addiction treatment for an individual (one) patient pending processing of this waiver notification.
S econd Notification - For physicians who submitted a new notification not less than one year ago and intend and need to treat up to 100 patients. (S ee Office of National Drug Control Policy Reauthorization Act of 2006.)

11. The S AMHS A Buprenorphine Physician and Treatment Program Locator Web site is publicly accessible at http://buprenorphine.samhsa.gov/bwns_locator/. The Locator Web site lists the names and practice contact
information of physicians with DATA waivers who agree to be listed on the site. The Locator Web site is used by the treatment-seeking public and health care professionals to find physicians with DATA waivers. The Locator
Web site additionally provides links to many other sources of information on substance abuse. No physician listings on the S AMHS A Buprenorphine Physician and Treatment Program Locator Web site will be made without
the express consent of the physician.

PRIVACY ACT INFORMATION
Authority: S ection 303 of the Controlled S ubstances Act of 1970 (21 US C § 823(g)(2)).
Purpose: To obtain information required to determine whether a practitioner meets the requirements of 21 US C § 823(g)(2).
Routine Uses: Disclosures of information from this system are made to the following categories of users for the purposes stated:
A. Medical specialty societies to verify practitioner qualifications.
B. Other federal law enforcement and regulatory agencies for law enforcement and regulatory purposes.
C. S tate and local law enforcement and regulatory agencies for law enforcement and regulatory purposes.
D. Persons registered under the Controlled S ubstance Act (PL 91-513) for the purpose of verifying the registration of customers and practitioners.
Effect: This form was created to facilitate the submission and review of waivers under 21 US C § 823(g)(2). This does not preclude other forms of notification.
Paperwork Reduction Act S tatement
Public reporting burden for completing this form is estimated to average 4 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the completed form. 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 0930-0234. S end comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to S AMHS A Reports Clearance
Officer; Paperwork Reduction Project (0930-0234); Room 3-1053, One Choke Cherry Road, Rockville, MD 20857