Travel Dosing for CompDrug Patients

Travel Dosing for CompDrug Patients
Patient Information

Questions about travel dosing? Visit our Travel Dosing webpage to learn about the process and what to expect.

Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SSN
Best callback number to reach you
Please enter a valid phone number.Format: (000) 000-0000.

Travel Dosing for CompDrug Patients
Destination Clinic Information

Please use the SAMHSA treatment locater to find an opioid treatment program (OTP) near your destination.

Need Help? Our Care Coordinators can help you complete this form or find a clinic near your destination. Call 614.586.7944 for assistance.

Please submit this form even if you have not yet found a clinic.

Have you already identified a clinic near your destination?
Name of Destination Clinic
Address of Destination Clinic

Street Address

Street Address Line 2

CityState / Province

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

Travel Dosing for CompDrug Patients
Review & Sign

What happens next? Our team will review your request and work with the destination clinic to coordinate your travel dosing. Travel dosing is not confirmed until arrangements have been completed with the destination clinic.

If travel dosing is arranged, we recommend confirming with the destination clinic 48–72 hours before your first dose.

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

Travel Information

Destination Clinic Information

Review & Sign