MH Licensure and Certification Section

Waiver Request
Opioid Treatment Program

TO: Robin Sulfridge, Section Chief

Division of Health Service Regulation
Mental Health Licensure and Certification
2817 Mail Service Center
Raleigh, North Carolina 27603

Facility Information
Date of Request
Person Completing Form and Title
Licensee
Name of Facility
Site Address
Phone Number
MHL#
FID #
Please Initial each box below Waiver Agreement and Acknowledgement

Licensee/Facility is requesting the Division of Health Service

Regulation (DHSR) waive 10A NCAC 27G. 3604 (f)(1)(A)-(G)
and (3)(A) to operate under the Substance Abuse and Mental
Health Services Administration’s (SAMHSA) temporary
exemptions, subject to the conditions identified below, from
the unsupervised take-home medication requirements of 42
C.F.R. § 8.12(i) (herein referred to as “SAMHSA’s temporary
exemption”). My initials and signature below indicate
my understanding and agreement to comply with the
SAMHSA temporary exemption and that DHSR has
authority to inspect the facility and take regulatory
action based on the facility's compliance with SAMHSA
temporary exemptions. My initials and signature below
also indicate the licensee for this facility has authorized me to
make this request and to agree with the conditions indicated
below.

In order for the facility to render care to its clients most

effectively, facility is requesting DHSR to waive 10A NCAC 27G.
3604 (f)(1)(A)-(G) and (3)(A) in exchange for facility agreeing
to comply with SAMHSA temporary exemption, subject to
applicable conditions, from the unsupervised take-home
medication requirements of 42 C.F.R. § 8.12(i) that are
necessary to:
(1) dispense up to 28 days of take-home doses of opioid use
disorder medication to stable patients if the OTP believes the
patient can safely handle this amount of take-home
medication; and

(2) dispense up to 14 days of take-home doses of opioid use

disorder medication to less stable patients if the OTP believes
the patient can safely handle this amount of take-home
medication.

See, Methadone Take-Home Flexibilities Extension Guidance | SA

Facility agrees DHSR will inspect its facility based on SAMHSA’s

temporary exemption pursuant to GS 122C-25.

This waiver will be in effect for the period of one year from the
end of the COVID-19 Public Health Emergency unless modified
or terminated by SAMHSA or DHSR.
In addition to taking other regulatory action, DHSR may
terminate this waiver if the facility is not in compliance with
SAMHSA’s temporary exemption or at any time
Attachment
Documentation of LME or LME-MCO governing body approval when
requests are from an LME or LME-MCO or contract agencies of an
LME or LME-MCO or documentation of governing body approval of
the facility when requests are from private facilities not contracting
with an LME or LME-MCO
Signature