Get Doh 4004

The Doh 4004 form is crucial for verifying the usage of controlled substances within emergency medical services in New York. This guide provides clear steps to help you complete the form accurately and efficiently.

Follow the steps to fill out the Doh 4004 online with confidence.

1. Click the ‘Get Form’ button to access the Doh 4004 form and open it in your designated online editor.
2. Begin by filling in the section for the name of the controlled substance being used. Make sure to accurately list the specific substance to ensure compliance.
3. In the 'Submitted to' field, indicate the name of the hospital or pharmacy where the controlled substance is being submitted.
4. Record the date on which you are completing the form next to the 'Date' field. This information is important for tracking purposes.
5. Enter the beginning inventory amount of the controlled substance in milligrams (mg) in the designated space. Ensure the amount reflects the accurate starting balance.
6. If applicable, include the PCR or tracking number for the substance. This helps maintain a clear record of the controlled substance's movement.
7. Fill in the 'Run ID/Number' to further identify the administration of the controlled substance.
8. In the section for the amount administered or destroyed, input the corresponding amounts in mg. Record each instance separately to maintain clarity and accuracy.
9. Calculate and enter the total quantity of the controlled substance administered to patients, ensuring that the total reflects all reported usages.
10. Next, indicate the total quantity of the controlled substance wasted or destroyed. This is crucial for accurate accountability.
11. Finally, input the ending inventory balance of the controlled substance in mg to finalize the report.
12. Complete the agency name section and print the agent's name clearly in the print name field.
13. Ensure that the agent's signature is included, confirming the accuracy of the information provided.
14. Fill out the NYS EMS Agency Code and NYS CS License No. as required.
15. Finally, review your completed form for any errors, save the changes, and then download, print, or share the document as needed.

Begin filling out the Doh 4004 online today to ensure accurate reporting of controlled substance usage.