Methadone Dispensing Form - OCPInfo.com

1 Methadone Dispensing Notification Form The Methadone Maintenance Treatment (MMT) and Dispensing Policy requires the owner/designated manager (DM) of a pharmacy to inform the College within seven days of starting to dispense Methadone for either Methadone maintenance treatment (MMT; for opioid addiction/dependence) or for pain/analgesia, and of changes in this status. New Initial Notification Pharmacy Information Change AOwner of Pharmacy/Corporation Name: Accreditation Number: Name of Pharmacy (by which the pharmacy is known to the public): Postal Code: Start Date of Methadone Dispensing : Stop Date of Methadone Dispensing : Hours of Operation Change B Sunday Monday Tuesday Wednesday Thursday Friday Saturday Holidays The DM must be trained via the CAMH Opioid Dependence Treatment (ODT) Core Course or approved course within six months of beginning this practice.

2 In addition, at least one staff pharmacist must complete this training requirement within one year. Note: Formal training is not mandatory if only Dispensing Methadone for pain; please refer to the Policy for details. Initial Training Declaration Change D Name of Designated Manager: OCP Number: Date Course Completed OR Course Registration Date (if known*): Signature: Name of Pharmacist: OCP Number: Date Course Completed OR Course Registration Date (if known*): Signature: *It is the member s responsibility to ensure they have sufficient skill, knowledge and competency to dispense Methadone in a safeand effective manner, prior to engaging in such practice. Additional education opportunities can be undertaken while concurrentlypursuing the required initial CAMH course registration. Refer to the Fact Sheet Key Requirements for Methadone completed form by email to or by fax to 416-847-8292, or by mail to the attention of Program Assistant, Pharmacy Assessments at 483 Huron St, Toronto, ON M5R 2R4 Version Number: Document Date: November 2017 Page 1 of 1 Description of Methadone Services Change CMethadone for Pain: Yes No Accepting new patients?

3 Yes No Methadone Maintenance Treatment (Addiction): Yes No Accepting new patients? Yes No Does the pharmacy transfer custody of Methadone doses to an exempted physician or his/her delegate? Yes No