Current through Register Vol. 48, No. 12, March 22, 2024
The Department will provide blanks of serially numbered
Official Medication Order Forms to authorized registrant hospital pharmacies.
The forms shall be in the following format:
A. HEADING SECTION
Each order form heading shall contain the following
information.
1. In the upper left hand
corner shall be printed "State of Illinois Department of Alcoholism and
Substance Abuse" with the agency telephone number.
2. In the upper middle portion, the name,
address and zip code of the hospital pharmacy shall be imprinted between the
prepunched holes. Below this, the DEA registration number for the hospital
pharmacy should appear. The individual registrant hospital pharmacy is
responsible to accomplish that printing, which may be typewritten or
stamped.
3. In the upper right hand
corner, the words "Order Serial Number" shall be imprinted. This order serial
number will serve as a control number and be placed on the hospital pharmacy's
dispensing label.
B.
TITLE SECTION
Order forms shall contain the following information in the
Title Section.
a) "RESEARCH ORDER FOR
DELTA-9-TETRAHYDROCANNABINOL MEDICATION."
b) "Valid for ONE bottle of NOT MORE THAN 25
capsules at the above pharmacy ONLY." This will explain to the patient that
this prescription can be filled only at the designated pharmacy indicated at
the top of the order form.
c) "This
order is NOT REFILLABLE." This will explain to the patient that this medication
cannot be refilled and that the patient's physician must issue a new written
order each time a patient requires Delta-9-Tetrahydrocannabinol
medication.
C. PHYSICIAN
SECTION
The physician's section shall contain the following
information:
1. The patient's name.
This will identify the person for which this medication is being
prescribed.
2. Date. This date will
signify the date on which the order was issued by the physician.
3. Patient's address. This will identify the
patient's place of residence and Zip Code.
4. Period covered by this order. This
information will provide the time frame in which the
Delta-9-Tetrahydrocannabinol medication is to be used by this patient. Any use
of the contents of this medication outside of the specified time periods
constitutes unauthorized use.
5.
Agent. If the patient is unable to pick up the medication in person, the
prescribing physician will designate an alternate, by name, to receive the
desired medication for delivery to the patient.
6. Delta-9-THC in
(
Strength) mg. in (
Written
Quantity) caps.
The strength of Delta-9-THC, whether 2.5 or 5.0 mg., should be
designated numerically in the first space. The quantity of Delta-9-THC capsules
should be written out in long hand to ensure that the correct quantity will be
dispensed and also to guard against alteration of the designated
quantity.
7. Sig. This
portion of the medication order form is provided for the physician to instruct
the patient as to frequency and quantity of the Delta-9-THC medication to be
administered during treatment.
8.
"PATIENT IS TO RETURN UNUSED MEDICATION." This is to explain to the patient
that unused medication must be returned to the hospital pharmacy for
disposal.
9. I AFFIRM THAT INFORMED
PATIENT CONSENT HAS BEEN OBTAINED. This statement is included on the form to
show patient consent prior to the administration of any medication. This
statement implies that the prescribing physician has informed the patient of
all risks and side effects associated with use of this medication, and this
statement is attested to by cosignatures of both patient and
physician.
10. M.D. ILLINOIS
CONTROLLED SUBSTANCES NUMBER. Obtained from the Department of Registration and
Education to permit ordering controlled substances.
11. M.D. DEA NUMBER. Obtained from DEA to
permit ordering controlled substances.
D. PHARMACY SECTION
When an order for Delta-9-Tetrahydrocannabinol has been
prepared by a hospital pharmacist for a patient, the dispensing pharmacist must
provide the following information on the lower portion of the order
form.
1. Date filled. The pharmacist
must enter in the appropriate space on the order form the actual date on which
the prescription was filled.
2. M.D.
HOSPITAL AFFILIATION. The pharmacist must check the list of enrolled physicians
and determine that the prescribing physician is eligible to order Delta-9-THC
through the hospital. If so, enter the word "Confirmed" in the space
provided.
3. RECIPIENT'S SIGNATURE.
The pharmacist must have the person who receives the medication sign for it,
whether it is the patient or another designated agent.
4. VERIFICATION OF RECIPIENT. If the person
receiving the ordered medication is a person other than the patient, the
pharmacist must take steps to ascertain that the individual is the designated
agent before releasing the medication. Identifying information, e.g., address,
phone number, drivers license number, may be indicated in this space.
5. R.P.H. SIGNATURE. The dispensing
pharmacist must sign the order form.