This form is used to cancel a permit to treat an opioid dependent person with methadone or burprenorphine held by the notifying practitioner.
use this form if you are notifying the department of a person's release from prison. Please use the Prison release notification
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.