Buprenorphine

Physicians can complete and submit a Waiver Notification Form (SMA-167) on-line, via fax, or by traditional mail. It is not mandatory to use the SMA-167 form to submit a waiver notification; however, CSAT does recommend the use of this form, either on-line or in hard copy, as it contains all the data items necessary to expedite the timely processing of waiver notifications. The qualifications necessary to receive a waiver are listed on this site under Physician Waiver Qualifications.

To complete the Waiver Notification Form on-line, use this link: Waiver Notification Form SMA-167

To download and/or print the Waiver Notification Form for completion and submission via fax or traditional mail (fax number and mailing address are listed on the form), use either of the links below:

HTML version of the Waiver Form

PDF version of the Waiver Form (PDF File, 130 Kb)

For Second Notifications—see Increase Patient Limits page.

How to Obtain a PDF Reader

Versions of Acrobat Reader exist for all major computer platforms, including Windows 98, Windows NT, Windows 2000, Windows ME, Macintosh, Sun, UNIX and several other operating systems. To download the reader, you’ll need a computer and a Web browser (such as Netscape Navigator or Internet Explorer) connected to the Internet. If you are using a modem to connect to the Internet, it may take you extra time to complete the download. Please follow the instructions on the Adobe Acrobat download page to install the Acrobat Reader.