Methadone Exemption Application

(For all practitioners practicing in the province of: Newfoundland, Prince Edward Island, Nova Scotia, New Brunswick, Saskatchewan, Alberta, Yukon, Northwest Territories and Nunavut)

1. Identification

• Applicant:
  • Physician
  • Veterinarian
  • Dentist
• Surname:
• Given Name:
• Licence(s)
• Specialty:
• Post Graduate Training:
• Primary Practice Address
  • Institution:
  • Street:
  • Room:
  • City:
  • PostalCode:
• Telephone:
• Fax:
• E-mail Address:
• Mailing Address (if different from above)
• Language
  • English
  • Français

2. Exemption

• Indication:
  • Dependency
  • Analgesia
• Type:
  • New
  • Renewal
  • Cancellation
• Other:
  • For one patient only
    • name of patient:
  • Correctionnal Services

3. Qualifications and Experience

• Describe qualifications and experience with methadone (courses, seminars, conferences, etc)
• Type of practice ( solo or group)

4. Declaration

By, this and under the condition that the released information is treated confidentially, I consent to the release from the licensing authority of the province or provinces in wich I am registered and entitled to practice, to the Office of Controlled Substances of information from my personal file pertaining to the review of my application to prescribe methadone or to any other action related to this request for an exemption.

Please send the application to the address below:

Methadone Programme
Evaluation and Authorization Division
Office of Controlled Substances
Health Canada
2nd Floor
123 Slater St
AL 3502B
Ottawa ON K1A 1B9

A copy of the application may be faxed to (613) 952-8576, however, the original must be sent by mail.

For further information, please contact the Evaluation and Authorization Division at (613) 946-5139 or toll free at 1-866-358-0453, by fax at (613) 952-8576 or by e-mail at exemption@hc-sc.gc.ca