SAMHSA OTP Mortality Report Form - aatod 2025

1. Click ‘Get Form’ to open the SAMHSA OTP Mortality Report Form in the editor.
2. Begin by filling out the Background Information section. Enter the Patient’s OTP ID No., Program OTP No., Date of Birth, Sex, ZIP Code of Residence, and Approximate Date of Death. Ensure all information is printed clearly.
3. In Section B, document the Date and Amount of Last Opioid Dose Dispensed Before Death. Include details about the Treatment Objective at Time of Death and specify if it was Induction, Maintenance, or Other.
4. Complete Section C by indicating the Last Time Dosed at Clinic and providing details on any split doses or take-home doses dispensed.
5. Proceed to Section D for the Most Recent Drug Test Date and any Positive Results. In Section F, indicate whether the cause of death is Preliminary (P) or Confirmed (C).
6. Fill out Sections G through J with relevant medical history, medications at last visit, a detailed description of events surrounding the death, and contact information for Medical Examiner/Coroner.
7. Once completed, review all entries for accuracy before saving your form. You can easily export or share it directly from our platform.

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