SAMHSA/CSAT Opioid Treatment Program (OTP) Extranet

CSAT's Division of Pharmacologic Therapies

1. Use this form to request a physician account on the SAMHSA OTP Extranet Web site to sign online patient exception requests.
2. Fill in all the fields on the right and click the "Submit" button at the bottom of the form.
3. After submitting your request, you will receive a confirmation email from the OTP Extranet system. Reply to this email to complete your request.
4. If you do not receive an email from SAMHSA within 24 hours, please re-submit this form. Make sure that you enter your email address correctly.
5. Once the SAMHSA Extranet receives your confirmation reply, it will email you login information and instructions for Extranet use.

All of the fields must be filled out.

First Name:	Last Name:
DegreeMD DO
OTP Name:	OTP ID Number: (e.g. AL-12345-M)
OTP Address Line 1:	Additional OTP IDs for which you would like access:
	(optional)
OTP City:	OTP State:
OTP Zip: (e.g. xxxxx)	OTP Phone Number: (e.g. xxx-xxx-xxxx)
Your Email Address:
Note: for security reasons, physician accounts must be established with an email address to which only the physician has access. We cannot accept an email address, such as ClinicName@yahoo.com,  to which multiple people have access.
Questions or problems? Contact the SAMHSA OTP Extranet Information Center by phone: 1-866-687-2728 or email: otp-extranet@opioid.samhsa.gov
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