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Getting Started

Notification of termination of methadone or buprenorphine program
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Who should complete this form
This form is used to cancel a permit to treat an opioid dependent person with methadone or burprenorphine held by the notifying practitioner. Notifications will be processed by Drugs and Poisons Regulation who can be contacted on 1300 364 545 or via email dpcs@dhhs.vic.gov.au

Do not use this form if you are notifying the department of a person's release from prison. Please use the Notification of release from prison of a patient treated with methadone or buprenorphine for opioid dependence form.

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

Notification of termination of methadone or buprenorphine program
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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

Notification of termination of methadone or buprenorphine program
Fields marked with * are required

Patient Details

Termination Details

Notification of termination of methadone or buprenorphine program
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Program Details

Which drug was last dosed on?

Dosing Point Details

Termination Details

Reason for termination: *

Declaration

Notification of termination of methadone or buprenorphine program
Fields marked with * are required

Declaration

I, confirm the information I provided in this notification is true and complete to the best of my knowledge. I confirm that is no longer attending for treatment on a program incorporating methadone or buprenorphine.

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 notification 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