Methadone Usage Summary Report
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Narcotic Enforcement
Public Health Law §3352
Persons certified pursuant to article twenty-three of the Mental Hygiene Law to operate Methadone Maintenance Treatment Programs (MMTP) shall keep records
showing the receipt, administration, dispensing, or destruction of all controlled substances and maintain the records in such manner and detail as the
Commissioner, by regulations, shall require.
By the tenth day of each month, a person certified to conduct a maintenance program shall file with the Department a report summarizing its activity in the
Program Name _________________________________________________________________________________________
Address __________________________________________ City__________________________ State _____ Zip___________
County ___________________________________________ Telephone ____________________________________________
DEA Number used for ordering Methadone __________________________________________________________________
Is DEA Number assigned to the MMTP?
Yes Name of MMTP ____________________________________
Do you receive Methadone from a wholesaler?
Yes Name of wholesaler _________________________________
DEA Number of wholesaler ________________________________
New York State OASAS Certificate Number _________________________________________________________________
For Month of
METHADONE ACTIVITY FOR THE MONTH
Express Amount in Grams, i.e. (245.56 gms)
Amount on hand at end of last month
Amount received during the month
Amount dispensed and administered this month
**Amount lost, stolen or unaccounted for
Amount on hand at end of the month
*Dosage form used (example: “Methadone-liquid 10mg/ml”, “Tablets 40mg/tablet”) __________________________________
**Loss, theft, or surrender of controlled substances must be reported. Briefly explain _________________________________
I certify that on ____/____/____, I have completed a physical inventory, as reported on this form. Any loss, theft, or surrender has
Print Name and Title
False statements made herein are punishable as a Class A misdemeanor pursuant to section 210.45 of the Penal Law.
Mail completed form to: Bureau of Narcotic Enforcement
Albany, NY 12204