Clinic Toolkit for Methadone Providers - Request Forms for Unlisted Drug Products from Ontario Drug Benefit

Request for Unlisted Drug Product (“Individual Clinical Review Form”): Naltrexone

Origin: Ministry of Health and Long-Term Care

Format: PDF

This is the Ministry’s standard ICR form for requesting an unlisted drug, with the appropriate fields pre-filled for Naltrexone in a standard dosage range. The form can be filled in onscreen using Adobe software or the information can be added using a typewriter after the form is printed. Completed forms should be faxed to the Ministry at 416 327-7526 or
(toll-free) 1 866 811-9908. To download a blank version of this form, visit: www.health.gov.on.ca/english/public/forms/form_menus/odb_fm.html

 

Request for Unlisted Drug Product (“Individual Clinical Review Form”): Suboxone

Origin: Ministry of Health and Long-Term Care | Format: PDF

This is the Ministry’s standard Individual Clinical Review (ICR) form for requesting an unlisted drug, with the appropriate fields pre-filled for Suboxone in a standard dosage range. The form can be filled in onscreen using Adobe software or the information can be added using a typewriter after the form is printed. Completed forms should be faxed to the Ministry at 416 327-7526 or (toll-free) 1 866 811-9908. To download a blank version of this form, visit: www.health.gov.on.ca/english/public/forms/form_menus/odb_fm.html.

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