Guest Dosing for Incarcerated Patients

Guest Dosing for Incarcerated Patients
Home Clinic Information

To be filled out by Home Clinic
Name of Home OTP
Address of Home OTP

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Clinic Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home OTP Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Home OTP Email
example@example.com

Guest Dosing for Incarcerated Patients

⚠️ Important Guidelines

✓ Maximum guest dosing period: 28 days

✓ Maximum dose administered: 300mg per day

✓ ROI & signed medication order required

✓ Notify CompDrug if services are canceled

Guest Dosing for Incarcerated Patients

⚠️ Important Guidelines

✓ Maximum guest dosing period: 28 days

✓ Maximum dose administered: 300mg per day

✓ ROI & signed medication order required

✓ Notify CompDrug if services are canceled

Guest Dosing for Incarcerated Patients
Review & Sign

Upload required documents.
Credential of person completing this form
Signature of person completing this form
Prohibition on Re-Disclosure

42 CFR part 2 prohibits unauthorized disclosure of these records
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Patient Information