New Brunswick Drug Plans uses this one-page form to request additional smoking cessation therapy for a patient: either more bupropion tablets or nicotine patches, but not both. Additional bupropion is capped at 168 tablets a year, and additional patches are restricted to people taking part in the Ottawa Model. The requestor records how many cigarettes the patient smoked per day before therapy and smokes now.
The prescriber (requestor) completes all five sections, from requestor and patient details to the therapeutic information and the signature with licence or registration number.
Download the current version from the source each time; forms change without notice.
Smoking Cessation Therapy Special Authorization Request
Thérapie d'abandon du tabac - Demande d'autorisation spéciale
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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No. FORM-917E states that requests are considered for bupropion tablets or nicotine patches, not both, so the requestor selects one. Bupropion is limited to 168 additional tablets a year, and additional patches are restricted to people participating in the Ottawa Model.
Additional nicotine patches are restricted to people participating in the Ottawa Model, and the form asks for the name of the participating hospital, clinic or health centre. The requestor also gives the number of patches per day, expected duration and cigarettes smoked daily before starting nicotine replacement and currently.
Yes. 'Thérapie d'abandon du tabac - Demande d'autorisation spéciale' is FORM-917F, the French counterpart of FORM-917E. The English form was revised in April 2024 and is faxed or mailed to the Special Authorization Unit of New Brunswick Drug Plans.