Form Sma 168 PDF Details

In the intricate landscape of healthcare administration, forms and documentation serve as the backbone for ensuring compliance, facilitating communication, and enhancing the quality of care. Among these, the SMA-168 form stands out as a particularly important document within the domain of opioid treatment programs (OTPs). Developed by the Substance Abuse and Mental Health Services Administration (SAMHSA), a branch of the Department of Health and Human Services, this form plays a crucial role in documenting exceptions for patients in opioid treatment settings. Designed under the regulatory framework of 42 CFR § 8.11(h), the SMA-168 form assists in the interagency review process by providing a structured format for submitting and justifying requests for exceptions to standard treatment protocols. Such exceptions could include requests for take-home medications, modifications in treatment protocols, or exemptions due to specific personal circumstances such as employment, medical issues, or family emergencies. Beyond its immediate administrative function, the form underscores the commitment of healthcare regulators and providers to accommodate the varying needs of individuals undergoing opioid treatment, balancing regulatory compliance with flexibility. The form not only details the specific nature of each request but also includes evaluation criteria for take-home medications and the requirement for a physician’s justification in certain scenarios. This process ensures each request is considered thoughtfully, acknowledging the individual's situation while maintaining the integrity and safety of the treatment program.

QuestionAnswer
Form NameForm Sma 168
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesotpsamhsa, 8-point, E-mail, Requestor

Form Preview Example

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Form Approved: OMB Number 0930-0206

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION

Expiration Date: 01/31/2010

CENTER FOR SUBSTANCE ABUSE TREATMENT

See OMB Statement on Reverse

 

Exception Request and Record of Justification

DATE OF SUBMISSION:

Under 42 CFR § 8.11(h)

 

Note: This form was created to assist in the interagency review of patient exceptions in opioid treatment programs (OTPs) under 42 CFR § 8.11(h).

Detailed INSTRUCTIONS are on the cover page of this form. PLEASE complete ALL applicable items on this form. Your cooperation will result in a speedy reply. Thank you.

INFORMATION

Program OTP No:

(e.g., AL-10001-M)

Program

Name:

Telephone:

Name & Title of Requestor:

-

 

 

 

 

 

-

 

Patient ID No:

 

 

 

 

 

 

 

 

 

Fax:E-mail:

BACKGROUND

REQUEST FOR CHANGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Methadone

 

 

 

 

 

LAAM

Buprenorphine

Patient’s Admission

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient’s current

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

dosage level:

 

 

 

 

 

 

 

 

 

mg

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient’s program attendance schedule per week

 

 

 

S

 

 

 

 

 

M

 

 

 

 

 

 

 

T

 

 

 

 

 

W

 

 

 

 

 

 

T

 

 

F

 

 

 

 

S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Place an “X” next to all days that the patient attends*):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*If current attendance is less than once per week, please enter the schedule:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient status:

 

 

 

 

Employed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Homemaker

 

 

 

 

 

 

 

 

 

 

Student

 

 

 

 

 

 

 

Disabled

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nature of Request:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Temporary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

take-home

 

 

Temporary change in

Detoxification

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

medication

 

 

protocol

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

exception

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Decrease regular attendance to

 

S

 

 

 

 

 

M

 

 

 

 

 

 

T

 

 

 

 

 

 

 

W

 

 

 

 

 

 

T

 

 

 

 

 

 

F

 

 

 

 

 

 

 

S

Beginning date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Place an “X” next to appropriate days*):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*If new attendance is less than once per week, please enter the schedule:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dates of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Exception:

From

 

 

 

to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

# of doses needed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Justification:

 

 

 

Family Emergency

 

 

 

 

 

Incarceration

 

Funeral

 

 

 

 

 

 

 

 

 

 

Vacation

 

 

 

 

 

 

Transportation Hardship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Long-Term Care

 

 

 

 

Other Residential

 

 

 

 

 

 

Step/Level Change

 

 

 

 

 

Employment

 

 

 

 

 

 

 

 

 

Medical

 

 

 

 

 

Facility

 

 

 

 

 

 

Treatment

 

 

 

 

 

 

 

Homebound

 

 

 

 

 

Split Dose

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REQUIREMENTS

Regulation Requirements:

1.For take-home medication: Has the patient been informed of the dangers of children ingesting methadone or LAAM?

2.For take-home medication: Has the program physician determined that the patient meets the 8-point evaluation criteria to determine whether the patient is responsible enough to handle methadone as outlined in 42 CFR § 8.12(i)(2)(i)-(viii)?

3.For multiple detoxification admissions: Did the physician justify more than 2 detoxification episodes per year and assess the patient for other forms of treatment (include dates of detoxification episodes) as required by 42 CFR § 8.12(e)(4)?

Submitted by:

Printed Name of Physician

Signature of Physician

Yes No N/A

Yes No N/A

Yes No N/A

Date

2007) (FRONT)

APPROVAL

State response to request:

 

Approved

 

 

 

Denied

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State Methadone Authority

Date

Explanation:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Federal response to request:

 

Approved

 

 

 

Denied

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Public Health Advisor, Center for Substance Abuse Treatment

Date

Explanation:

 

 

 

 

 

 

 

 

 

Please fax to CSAT/DPT at (240) 276-1630 or e-mail: otp@samhsa.hhs.gov

This exception is contingent upon approval by your State Methadone Authority (as applicable) and may not be implemented until you receive such approval.

FORM SMA-168 (revised January

Purpose of Form: This form was created to facilitate the submission and review of patient exceptions under 42 CFR § 8.11(h). This does not preclude other forms of notification.

Paperwork Reduction Act Statement

Public reporting burden for this collection of information is estimated to average 25 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to SAMHSA Reports Clearance Officer; Paperwork Reduction Project (0930-0206); Suite 7-1043, 1 Choke Cherry Road, Rockville, MD 20857. An agency

may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a

currently valid OMB control number. The OMB control number for this project is 0930-0206.

FORM SMA-168 (revised January 2007) (BACK)

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Stage number 1 for submitting form 168

2. Soon after filling in this step, head on to the next stage and fill in all required details in all these blank fields - Temporary takehome medication, Temporary change in protocol, Detoxification exception, Other, Decrease regular attendance to, If new attendance is less than, From, Beginning date, of doses needed, Justification, Family Emergency, StepLevel Change, Homebound, Incarceration, and Employment.

Learn how to prepare form 168 part 2

People generally make some mistakes while filling in Temporary takehome medication in this section. You should re-examine whatever you type in here.

3. This third stage is hassle-free - fill out all of the fields in L A V O R P P A, Date, T N O R F y r a u n a J d e, v e r A M S M R O F, State response to request, Approved, Denied, Explanation, Federal response to request, Approved, Denied, Explanation, State Methadone Authority, Public Health Advisor Center for, and Date to finish this part.

Part # 3 for completing form 168

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