Controlled Substance Prescribing Compliance Waiver Tracking Log
Please complete all fields to accurately log compliance waivers related to controlled substance prescribing.
Date of Entry
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Provider Name
*
First Name
Last Name
Patient Initials
*
Waiver Type
*
Please Select
Opioid Prescribing Limit Waiver
Benzodiazepine Prescribing Waiver
Stimulant Prescribing Waiver
Other
Prescribing Reason/Category
*
Please Select
Chronic Pain Management
Acute Pain
Palliative Care
Mental Health
Other
Compliance Status
*
Compliant
Non-Compliant
Pending Review
Reviewer Initials
*
Review Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Notes or Comments
Submit Log Entry
Should be Empty: