Guest Dose Request Form (Sending Clinic)

Guest Dose Request Form (Sending Clinic)

Fill out this form if you are an OTP/NTP clinic looking to send a patient to a BrightView clinic to Guest Dose. Please note that guest dose trips are not set up until BrightView contacts the sending clinic to confirm dose information.
Patient Name*
First and last name
Patient DOB*

MonthDayYear
Date
Patient Address
Patient Phone Number
Reason for Travel
Travelling To*

KentuckyMarylandNorth CarolinaOhioVirginia
Ohio Site*
Kentucky Site*
Massachusetts Site*
Maryland Site*
North Carolina Site*
Virginia Site*
Patient Diagnosis Code(s)
Medication*

MethadoneBuprenorphineBuprenorphine/Naloxone
Patient Current Dose*
Dosage in mgs
Split Dose

YesNo
Date Last Medicated at Home Facility

MonthDayYear
Date
Take Homes Received
Quantity of doses sent with patient
Total Take Homes Allowed per Week
Quantity allowed per week
Current Dosing Schedule at Clinic

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Start Guest Dosing Date*

MonthDayYear
Date
End Guest Dosing Date*

MonthDayYear
Date
Total Days
Travel Dose Required

YesNo
Urine Drug Screen requested during Guest Dosing

YesNo
Please attach the following information:
Signed Release of Information
Current OTP Methadone Order (or change order)
Three (3) most recent urine drug screens
Copy of ID
Copy of Insurance card, if applicable
Attachment(s)

Cancelof
Sending Clinic Name*
Clinic Address*
Clinic Phone Number*
Fax Number
Please enter a valid phone number.
Contact name
Guest Dosing at BrightView
- Our clinics are closed on Sundays. Maryland clinics are closed Saturdays and Sundays.
- BrightView charges $13 per dose unless otherwise specified based on insurance type
- Valid form of ID is required at time of dosing
Should be Empty: