Form Sma 168 – Fill Out and Use This PDF

Form Sma 168 is a widely respected intervention in its field. Developed by academic researchers with expertise and experience from related disciplines, it has earned popularity for being structured, organized and extremely time efficient. It focuses on the core concepts of the topic at hand and incorporates strategies that enable participants to utilize their own experiences to internalize the learning process. It has made significant contributions in the areas of personal growth, team collaboration and leadership development, making it a useful tool for business and educational purposes alike.

Form Sma 168 PDF Details

If you're like most small business owners, you are always looking for ways to save money and increase profits. One way to do both of those things is by taking advantage of tax deductions available to small businesses. Form Sma 168 is one of the most commonly used small business tax deductions. In this post, we'll explain what Form Sma 168 is and how you can use it to reduce your taxes. We'll also provide a few examples so that you can see how the deduction works in practice. Thanks for reading!

Question	Answer
Form Name	Form Sma 168
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	otpsamhsa, 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	Expiration Date: 01/31/2010
	CENTER FOR SUBSTANCE ABUSE TREATMENT	See OMB Statement on Reverse
		See OMB Statement on Reverse

	Exception Request and Record of Justification	DATE OF SUBMISSION:
	Under 42 CFR § 8.11(h)	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:

Other:

Patient’s program attendance schedule per week

(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

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

# 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

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)

How to Edit Form Sma 168 Online for Free

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Step 1: First, access the pdf editor by clicking the "Get Form Button" in the top section of this site.

Step 2: As soon as you access the online editor, there'll be the document ready to be filled out. Aside from filling out different fields, you could also do other things with the PDF, including writing any textual content, editing the original textual content, adding images, placing your signature to the form, and a lot more.

As for the blank fields of this particular form, here is what you should know:

1. While filling out the opioid, make certain to incorporate all needed fields in its relevant area. It will help to facilitate the process, allowing for your details to be handled efficiently and appropriately.

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.

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.

Step 3: Once you've looked over the details in the fields, simply click "Done" to finalize your FormsPal process. Try a 7-day free trial subscription with us and gain immediate access to opioid - downloadable, emailable, and editable in your personal account. FormsPal provides secure document tools with no data record-keeping or distributing. Be assured that your information is safe here!

Form Sma 168 – Fill Out and Use This PDF

Form Sma 168 PDF Details

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