NP Application for Authority to Prescribe Methadone for Opioid Dependence Part A (Initial application)

Transcription

1 NP Application for Authority to Prescribe Methadone for Opioid Dependence Part A (Initial application) Complete each section and initial the bottom of each page. Section A: Name ARNNL NP Licensure/Registration # Phone Number Primary Address Address Manager Name Phone Number Employer(s) Address (include site/unit) Prescribing indication: Opioid Dependence Provide a description of your practice setting and applicability for this request to prescribe Methadone for opioid dependence: Section B: Confirm access to collaboration and supports in your practice setting: Employer support for prescribing methadone for opioid dependence: Y N Access to employer policies for prescribing methadone for opioid dependence: Y N Access to program/laboratory services for the regular testing of patients for drugs of abuse: Y N Access to an experienced methadone prescriber for consultation/mentoring Y N Registered with the Pharmacy Network and have access to the Pharmacy Network for purposes of reviewing a patient s medication profile Y N Education and Training (attach certificates/documentation confirming completion): Centre for Addiction and Mental Health(CAMH) Opioid Dependence Treatment (ODT) Core Course: Y N College of Physicians and Surgeons of NL (CPSNL) Introduction to Safe Prescribing: Opioids, Benzodiazepines and Stimulants: Y N Clinical training (minimum of two days) with an experienced methadone provider/team: Y N Initials 1

2 Section C: NP Application for Authority to Prescribe Methadone for Opioid Dependence Part A (Initial application) Letters of Support (attach a letter of support from your current nursing manager/supervisor confirming their support for you to prescribe methadone for opioid dependence. Manager/Supervisor Name: Manager/Supervisor contact information: Section D: NPs employed outside a Regional Health Authority: Identify the name and contact information of a mentor (who may be different from your collaborating physician) and who has expertise in addictions management and/or substance use disorders and expertise in prescribing Methadone. Mentor Name Mentor Contact Information/Phone Number Attach the policies that guide your practice in relation to prescribing Methadone and care of patient receiving Methadone for opioid dependence: Policies attached Y N Initials 2

3 NP Application for Authority to Prescribe Methadone for Opioid Dependence Part A (Initial application) Section E: Nurse Practitioner s Declarations I hereby apply for authority to prescribe methadone for opioid dependence and declare that the information I have provided in this application is true and correct. I declare that I am knowledgeable of the current version of the CPSNL s Methadone Maintenance Treatment Standards and Guidelines document. I declare that I am knowledgeable of the current version of the Newfoundland & Labrador Pharmacy Board s (NLPB) Standards for the Safe and Effective Provision of Methadone for the Treatment of Opioid Dependence. I declare that, when necessary, I will consult with more experienced prescribers of Methadone to enhance my knowledge and ensure patient safety as needed during induction or re-induction after missed doses. I understand that I am required to complete the CAMH Opioid Dependence Treatment Certificate Program or a course/education program deemed equivalent by ARNNL as part of continuing education in opioid dependence within three years of being granted Authority to prescribe Methadone for opioid dependence. I hereby give consent to the ARNNL to obtain confirmation or verification of the documentation and information submitted as part of this application, including but not limited to contacting my employer, manager or mentor. I understand that a link to the names of authorized prescribes will display to the ARNNL member search I declare that I have read and agree with each of the declaration statements listed above. NP Signature If you have more than one practice setting where Methadone for Opioid Dependence is prescribed you must contact ARNNL for further direction. When ARNNL reviews your application, you will be notified by when authority to prescribe Methadone for opioid dependence has been granted. For Office Use Only: Part A Received: Part B Received: Part C Received: Part D Received: Approved: Signature: Initials 3

4 NP Prescriptive Authority: Methadone for Opioid Dependence Part B: Employer Statement Please complete Section A and forward this form to the Program Manager/Nurse Manager/Supervisor at place(s) of employment requesting completion. Section A: Nurse Practitioner Information Surname Given Name Telephone Number Address ARNNL NP Registration/Licensure # I hereby give consent for my employer to release the information as requested by ARNNL. Signature of Nurse Practitioner Section B: Statement of Current Employer The above-named Nurse Practitioner has applied to ARNNL to be granted the authority to prescribe Methadone for Opioid Dependence in his/her NP practice. Please complete the following statement indicating the employer s support for this nurse practitioner to prescribe Methadone for Opioid Dependence. Please return the completed document directly to ARNNL at registration@arnnl.ca. Employer Name: Employer Address: Do you support this NP to prescribe Methadone for Opioid Dependence in their current practice setting: Y N Do you confirm that the employer has a policy(s) in place to guide a NP in their practice to prescribe Methadone for Opioid Dependence and care of clients receiving Methadone for Opioid Dependence: Y N Do you confirm that the above named Nurse Practitioner has access to a mentor who has expertise in prescribing Methadone for Opioid Dependence: Y N Signature Position/Title

5 NP Prescriptive Authority: Methadone for Opioid Dependence Part C: Confirmation of Clinical Training Please complete Section A and forward this form to the methadone provider/team who provided clinical training. Section A: Nurse Practitioner Information Surname Given Name Telephone Number Address ARNNL NP Registration/Licensure # I hereby give consent for my employer to release the information as requested by ARNNL. Signature of Nurse Practitioner Section B: Statement of Methadone Provider/Team who provided Clinical Training The above-named Nurse Practitioner has applied to ARNNL to be granted the authority to prescribe Methadone for Opioid Dependence in his/her NP practice. In accordance with ARNNL policy an NP must complete a minimum of two days of clinical training with an experienced methadone provider/team prior to be granted prescriptive authority for Methadone for Opioid Dependence. Please complete the following statement confirming this Nurse Practitioner s completion of clinical training. Please return the completed document directly to ARNNL at registration@arnnl.ca. On the above-named nurse practitioner completed two days of clinical training with, an experienced Methadone provider/team at. Name Location/Program Signature Position/Title

6 NP Prescriptive Authority: Methadone for Opioid Dependence Part D: Confirmation of Mentor FOR NURSE PRACTITIONERS (NPs) WHO ARE EMPLOYED OUTSIDE OF A REGIONAL HEALTH AUTHORITY IN NEWFOUNDLAND AND LABRADOR (INCLUDES SELF EMPLOYMENT) I, understand that it is a requirement of Council to be granted authority to prescribe Methadone for Opioid Dependence that I have access to a mentor who has expertise in prescribing Methadone for Opioid Dependence. I, confirm that I have access to a mentor with expertise in prescribing Methadone for Opioid Dependence. The employer s name is: The Mentor s name is: Employer s address and contact information: Mentors address and contact information: I understand that I am required to immediately notify ARNNL should any of the information provided above change, with respect to access to a mentor. Nurse Practitioners Signature: Mentor s Signature: : : Mentor License #: