NP Application for Authority to Prescribe Buprenorphine-Naloxone (Suboxone) Part A

Transcription

1 NP Application for Authority to Prescribe Buprenorphine-Naloxone (Suboxone) Part A 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) Provide a description of your practice setting and applicability for this request: Section B: Confirm access to the Council required collaboration and supports in your practice setting: Employer support for prescribing Buprenorphine-Naloxone (Suboxone): Y N Access to employer policies for prescribing Buprenorphine-Naloxone (Suboxone): Y N Access to program/laboratory services for the regular testing of patients for drugs of abuse: Y N Access to a mentor who has expertise in addictions management and/or substance use disorders and expertise in prescribing Buprenorphine-Naloxone (Suboxone): 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 (attached certificates/documentation confirming your completion): Complete the online Suboxone education program on the prescribing of Buprenorphine-Naloxone (Suboxone) available at or a course/education program deemed equivalent by ARNNL: Y N Complete the Centre for Addiction and Mental Health (CAMH) Buprenorphine-Assisted Treatment of Opioid Dependence: An online course for front-line clinicians or a course/educational program deemed equivalent by ARNNL: Y N College of Physicians and Surgeons of NL (CPSNL) ntroduction to Safe Prescribing: Opioids, Benzodiazepines, and Stimulants Course: Y N Clinical training (minimum of two days) with an experienced Buprenorphine-Naloxone (Suboxone) prescriber/team: Y N nitials 1

2 NP Application for Authority to Prescribe Buprenorphine-Naloxone (Suboxone) Part A Section C: Letters of Support (attach a letter of support from your current nursing manager/supervisor confirming their support for you to prescribe Buprenorphine-Naloxone (Suboxone)) Manager/Supervisor Name: Manager/Supervisor contact information: Section D: NPs employed outside a Regional Health Authority: dentify 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 Buprenorphine-Naloxone (Suboxone): Mentor Name Mentor Contact nformation/phone Number Address Attach the policies that guide your practice in relation to prescribing Buprenorphine-Naloxone (Suboxone) and care of patient receiving Buprenorphine-Naloxone (Suboxone): Policies attached Y N nitials 2

3 Section E: NP Application for Authority to Prescribe Buprenorphine-Naloxone (Suboxone) Part A Nurse Practitioner s Declarations hereby apply for the authority to prescribe Buprenorphine-Naloxone (Suboxone) and declare that the information have provided in this application is true and correct. declare that am knowledgeable of the current version of the CPSNL s Methadone Maintenance Treatment Standards and Guidelines document. declare that am knowledgeable of the current version of the Newfoundland and Labrador Pharmacy Board s (NLPB) Standards for the Safe and Effective Provision of Medication for the Treatment of Opioid Dependence. declare that, when necessary will consult with more experienced prescribers of Buprenorphine-Naloxone (Suboxone) to enhance my knowledge and ensure patient safety as needed during induction or re-induction after missed doses. understand that am required to complete the Centre for Addiction and Mental Health (CAMH) Opioid Treatment (ODT) core course or a course/educational program deemed equivalent within 18 months of being granted authority to prescribe Buprenorphine-Naloxone (Suboxone). understand that 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 Buprenorphine-Naloxone (Suboxone). 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. understand a link to the names of authorized prescribers will display to the ARNNL member search declare that have read and agree with each of the declaration statements listed above. NP Signature f you have more than one practice setting where Buprenorphine-Naloxone (Suboxone) is prescribed, append information for each practice setting, along with the employer and supervisor name for each practice setting. When ARNNL reviews your application, you will be notified by when authority to prescribe Buprenorphine- Naloxone (Suboxone) has been granted. For Office Use Only: Part A Received: Part B Received: Part C Received: Approved: Part D Received: Signature: nitials 3

4 NP Prescriptive Authority: Buprenorphine-Naloxone (Suboxone) Part B: Employer Statement Please complete Section A and forward this form to the Program Manager/Nurse Manager/Supervisor at place(s) of employment for completion. Section A: Nurse Practitioner nformation Surname Given Name Telephone Number Address ARNNL NP Registration/Licensure # 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 Buprenorphine- Naloxone (Suboxone) in his/her NP practice. Please complete the following statement indicating the employer s support for this nurse practitioner to prescribe Buprenorphine-Naloxone (Suboxone). Please return the completed document directly to ARNNL at registration@arnnl.ca. Employer Name: Employer Address: Do you support this NP to prescribe Buprenorphine-Naloxone (Suboxone) 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 Buprenorphine- Naloxone (Suboxone)and care of clients receiving Buprenorphine-Naloxone (Suboxone): Y N Do you confirm that the above named Nurse Practitioner has access to a mentor who has expertise in prescribing Buprenorphine-Naloxone (Suboxone): Y N Signature Position/Title

5 NP Prescriptive Authority: Buprenorphine-Naloxone (Suboxone) Part C: Confirmation of Clinical Training Please complete Section A and forward this form to the Buprenorphine-Naloxone (Suboxone) provider/team who provided clinical training. Section A: Nurse Practitioner nformation Surname Given Name Telephone Number Address ARNNL NP Registration/Licensure # hereby give consent for my employer to release the information as requested by ARNNL. Signature of Nurse Practitioner Section B: Statement of Suboxone Provider/Team who provided of Clinical Training The above-named Nurse Practitioner has applied to ARNNL to be granted the authority to prescribe Buprenorphine- Naloxone (Suboxone) in his/her NP practice. n accordance with ARNNL policy, an NP must complete a minimum of two days of clinical training with an experienced suboxone provider/team prior to be granted prescriptive authority for Buprenorphine-Naloxone (Suboxone). 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 Buprenorphine-Naloxone (Suboxone) provider/team at Name. Location/Program Signature Position/Title

6 NP Prescriptive Authority: Buprenorphine-Naloxone (Suboxone) Part D: Confirmation of Mentor FOR NURSE PRACTTONERS (NPs) EMPLOYED WTH AN EMPLOYER THAT S NOT A REGONAL HEALTH AUTHORTY N NEWFOUNDLAND AND LABRADOR (NCLUDES SELF EMPLOYMENT), understand that it is a requirement of Council to be granted authority to prescribe Buprenorphine-Naloxone (Suboxone) that have access to a mentor who has expertise in prescribing Buprenorphine-Naloxone (Suboxone)., confirm that have access to a mentor with expertise in prescribing Buprenorphine-Naloxone (Suboxone). The Employer s name is: The Mentor s name is: Employer s address and contact information: Mentors address and contact information: understand that 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 #: