Form sma 168 printable 2026

1. Click ‘Get Form’ to open the SMA 168 form in the editor.
2. Begin by filling out the 'Background Information' section. Enter the Program OTP No, Patient ID No, and Program Name accurately. Ensure you include your contact details such as telephone, fax, and email.
3. In the 'Patient's Admission Date' field, input the date when the patient was enrolled at your facility. Next, indicate the patient's current dosage level and select the medication type by placing an 'X' next to Methadone/LAAM/Other.
4. Complete the attendance schedule by marking each day of the week that the patient attends. If attendance is less than once a week, specify this in the provided space.
5. For any requests for changes in treatment, fill out the 'Request for Change' section. Clearly indicate the nature of your request and provide justification as needed.
6. Finally, ensure all sections are completed before signing and dating at the bottom of the form. Once finished, submit it via fax or email as instructed.

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