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Arizona Medical Board (Arizona Medical Board)

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Arizona Medical Board
1740 W. Adams Street, Suite 4000
Phoenix, AZ 85007
Phone: (480) 551-2700 Fax: (480) 551-2702
Website: www.azmd.gov
DATA Waiver Eligibility Fact Sheet
Effective August 27, 2019, the Board will begin accepting the DATA Waiver Eligibility application pursuant to the Drug Addiction
Treatment Act of 2000 (DATA Waiver Eligibility) to practice opioid use disorder treatment in an outpatient facility.
A completed application must be submitted in PDF format to Michelle.Robles@azmd.gov.
The application must not be more than 10 pages.
Board Staff will review the application for completeness and place it on the Board’s agenda for
review and action. A public meeting notice letter will be sent to the address on the application
informing the applicant of date and time of review by the Board. Please be aware that an
incomplete application will be considered deficient and will not move forward for review by the
Board until all required information is received.
If approved by the Board, the training facility shall submit a list in Excel format with the name and
address of all recipients of the training indicating they’ve met the requirements of the Board
approved curriculum/training and that they are DATA Waiver Eligible. Upon receipt of the list of
names the Board will issue a written notice to each qualified physician.
Example of Excel format:
Full Name (First and Last Name)
Street Address
Suite, Floor, Apt #
City
State
Zip
Upon receipt of the full DEA license, a physician with an approval letter for DATA waiver from
the Board may submit the Board letter to SAMHSA for approval at
http://buprenorphine.samhsa.gov/forms/select-practitioner-type.php.
If the initial application is denied, the Board will send written notice informing applicant of the
action. There may be a single appeal for reconsideration of the waiver application.
Arizona Medical Board
1740 W. Adams Street, Suite 4000
Phoenix, AZ 85007
Phone: (480) 551-2700 Fax: (480) 551-2702
Website: www.azmd.gov
DATA Waiver Eligibility Application
Name of Institution, School or Individual:
First Name: Last Name:
Mailing Address:
City: State: Zip Code:
Email Address:
Number of Individuals receiving training or education:
Brief description of training or experience:
Please include supporting documentation that shows that the training or experience addresses
the following (please note: application must not be more than 10 pages long):
a.
Opioid maintenance and detoxification
b.
Appropriate clinical use of all drugs approved by the Food and Drug Administration for the
treatment of opioid use disorder
c.
Initial and periodic patient assessments (including substance use monitoring)
d.
Individualized treatment planning, overdose reversal, and relapse prevention
e.
Counseling and recovery support services
f.
Staffing roles and considerations
g.
Diversion control
Please check a box:
I hereby certify I am an authorized individual to sign and submit this waiver application.
I hereby certify I am authorized to sign and submit this waiver application on behalf of the
above named facility.
Signature:
Date:
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Completed 20 July 2020

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