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Ns issued to RPAs by the Department of Health must contain the imprinted names of both the RPA and his or her supervising physician, pursuant to Section 94.2 of Title 10. Please complete and enclose this form with your registration form for the Official Prescription Program. I. To Be Completed by Supervising Physician I hereby authorize (Name of RPA) to order official New York State prescriptions from the New York State Department of Health impr.

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Filling out the Xdibos form online is a straightforward process designed to help users easily navigate through the required fields. This guide will walk you through each section of the form, ensuring that you complete it accurately and efficiently.

Follow the steps to complete your Xdibos form online.

  1. Click ‘Get Form’ button to obtain the form and open it in an online editor. This action will allow you to access the necessary fields for completion.
  2. Begin with Section I, to be completed by the supervising physician. Enter the name of the registered physician assistant (RPA) who is authorized to order official New York State prescriptions. This should be clearly printed.
  3. In the same section, the supervising physician must provide their New York State license number and, if applicable, their DEA registration number.
  4. The supervising physician must sign and date this section, indicating their commitment to inform the Bureau of Narcotic Enforcement if the supervisory relationship changes.
  5. Next, move to Section II, which is to be completed by the RPA. The RPA must print their own name and include their New York State license number.
  6. Further, the RPA needs to provide their DEA registration number in this section.
  7. The RPA must also sign and date this section, noting that they will promptly notify the Bureau of Narcotic Enforcement should their association with the supervising physician discontinue.
  8. Review the entire form for accuracy. Once all necessary fields have been filled out, you can proceed to save changes, download the completed form, and share or print it as needed.

Complete your Xdibos form online today to ensure a smooth and efficient process.

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