EMERGENCY FAX METHADONE MAINTENANCE CONTROLLED PRESCRIPTION FORM DOCUMENTATION

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FEDERAL EMERGENCY MANAGEMENT AGENCY PROJECT WORKSHEET OMB NO
COUNTY EMERGENCY OPERATIONS PLAN COUNTY KENTUCKY EMERGENCY

COUNTY EMERGENCY OPERATIONS PLAN “ONE TEAM ONE MISSION
EMERGENCY 000 OR 112 131 444
EMERGENCY TRIAGE EDUCATION KIT

Methadone Maintenance Treatment Emergency Fax Methadone Maintenance Controlled Prescription Form Documentation

Emergency Fax Methadone Maintenance Controlled Prescription Form Documentation


This form is for the use only in the event of an emergency that requires a faxed Methadone Maintenance Controlled Prescription form and has been initiated following direct consultation between the patient’s pharmacist and prescriber.


It is understood that the pharmacist must obtain written documentation from the prescriber prior to dispensing any medication and as such is requesting that the prescriber complete this form and fax back to the pharmacy along with a fax of the Methadone Maintenance Controlled Prescription form as soon as possible.




Prescriber: Patient Name:


Pharmacy: Fax Number:


Pharmacist: Date:




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Affix Methadone Maintenance Controlled Prescription form here

s the prescribing physician, I request that the above-named pharmacy accept a faxed transmission of the Methadone Maintenance Controlled Prescription form for the above-named patient. I understand that the Methadone Maintenance Controlled Prescription form must be faxed to and received by the pharmacy prior to the pharmacy dispensing methadone. In accordance with the most current versions of the CPSBC Methadone Maintenance Handbook I guarantee that the original Methadone Maintenance Controlled Prescription form will be sent to the pharmacy by the next business day.




Brief Description of the emergency situation:








Prescriber’s Name:


CPSID:


Prescriber’s Signature:


Signature Date:

131984.doc Rev 2013-09-20


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Tags: controlled prescription, maintenance controlled, maintenance, emergency, documentation, methadone, controlled, prescription