§2085.EXHIBIT C. Special Instructions Covering Research Medication Order Forms for Delta-9-Tetrahydrocannabinol

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.