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Getting Started

Application for a permit to treat an opioid dependent person with methadone or buprenorphine
Fields marked with * are required
Do you need to complete this form?
This form is for prescribers who need to apply for a permit to treat an opioid dependent person with methadone or buprenorphine for opioid replacement therapy (pharmacotherapy permit).

If the patient is a hospital in-patient, is in an aged care service or is a prisoner being treated in prison, do not use this form. Instead please complete Notification of drug dependent person form.Note: Once you have completed and submitted this form, you will receive a confirmation email that your completed form has been received by the department, as well as a PDF of your completed form for your records.

To save time filling out the form in the future, please tick the checkbox at the end of the form to confirm that you want to save your Prescriber Details on this computer. Future use of this form on this computer will automatically populate with your Prescriber Details.

Prescriber Details

Application for a permit to treat an opioid dependent person with methadone or buprenorphine
Fields marked with * are required

Your details

To save time filling out the form in the future, please tick the checkbox at the end of this form to confirm that you want to save your Prescriber Details on this computer. Future use of this form on this computer will automatically populate with your Prescriber Details.

Patient Details

Application for a permit to treat an opioid dependent person with methadone or buprenorphine
Fields marked with * are required

Patient Details

Treatment Details

Application for a permit to treat an opioid dependent person with methadone or buprenorphine
Fields marked with * are required

Treatment details

Is this permit for ongoing treatment?
Is currently being treated with methadone and/or buprenorphine (including treatment in prison, hospital or interstate)?
This is the date last received a dose.
Have you informed that is transferring to your care?
You must contact to advise patient's transfer of care. A permit cannot be issued if is not informed of 's transfer.

Dose details

Starting Drug
This is the date of the NEXT dose under your care and cannot be before or the same as
This is the anticipated date of first dose under your care

Dosing point details

Additional Comments

1.If your application has a Start Date of tomorrow or later (max. 3 days later), please state below if you wish to have your application processed today.2.If the patient is currently being treated by another prescriber with other Schedule 8 opioids (e.g. oxycodone) please include below the details of the other prescriber and confirm they have been informed that you are intending to treat this patient with METHADONE or BUPRENORPHINE for opioid dependence and that they have ceased treating the patient.
Additional information
File:

Declaration

Application for a permit to treat an opioid dependent person with methadone or buprenorphine
Fields marked with * are required

Declaration

This application forms part of a legal document and penalties exist for providing false or misleading information.

I, certify that this patient shows evidence of dependence on an opioid drug and that, in my opinion, an opioid substitute is required in support of treatment. The information provided in this application is true and complete to the best of my knowledge.

Privacy Statement

It is a requirement of the Drugs, Poisons and Controlled Substances Act 1981 (the Act) that the information set out in this form is provided to the Department of Health & Human Services to meet statutory notification requirements, and for the issuing of permits as required under the Act. The collection, use and disclosure of the information provided will be in accordance with the law, including the provisions of the Health Records Act 2001. The information collected may be disclosed to health practitioners practising in the following health professions: medical, nursing and midwifery and pharmacy, when necessary to facilitate coordination of the patient's drug treatment and safe prescribing of drugs. For example, it may be necessary to disclose this information when another health practitioner applies for a permit or is considering prescribing a drug of dependence. The application may not be processed if all information requested on the form is not completed.

Remember Me

You can save time filling out the form by ticking the checkbox below. Your Prescriber Details will be saved and future use of this form on this computer will automatically populate with your Prescriber Details. Do not tick the checkbox below if this is a public/shared computer as it may compromise your privacy and security.
By unticking the checkbox below the Prescriber Details that have been saved on this computer will be removed.
Prescriber Details prefilled
Department of Health & Human Services