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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.

Do not use this form if you are notifying the department of a person's release from prison. Please use the Prison release notification form.

Registered Medical Practitioner / Nurse Practitioner Details

Notification of termination of methadone or buprenorphine program
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Your Details (Prescriber Details)

Patient Details

Notification of termination of methadone or buprenorphine program
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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
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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 Collection Notice

By completing this form, you acknowledge that you are providing the personal and health information as required under the Drugs, Poisons and Controlled Substances Act 1981 (the Act) to the Department of Health, Victoria (the Department) for the purpose of notifying the Department in relation to a Schedule 8 treatment permit.

The information is handled by the Department in accordance with the requirements of the Act, Drugs, Poisons and Controlled Substances Regulations 2017 (Vic), Privacy and Data Protection Act 2014 (Vic), Health Records Act 2001 (Vic) and the Department’s privacy policy.

The information collected by the Department:

will be used and disclosed for the purposes of assessing a permit application;will be used and disclosed for monitoring and compliance purposes;may be disclosed to other relevant health practitioners when necessary to facilitate coordination of the patient's drug treatment and safe prescribing of drugs (if applicable); andmay be disclosed for any other purposes permitted by law including but not limited to reporting or investigation of suspected unlawful activity to regulatory and law enforcement agencies in the Commonwealth, States and Territories; and Ahpra.
If you do not provide all the required information, the notification may not be processed.

You can download a PDF copy of the completed form or request a confirmation email at the Submission Complete page.

For further information about Victorian Drugs and Poisons legislation, please visit the Medicines and Poisons Regulation website at www.health.vic.gov.au/dpcs.

For further information on privacy and how to access and seek correction of personal information about you held by the Department, visit www.health.vic.gov.au/privacy.

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 (VIC) - Medicines and Poisons Regulation