Get NY DOH-4329 2012

PLEASE MAIL COMPLETED FORM S TO ADDRESS BELOW Faxes are not accepted NYSDOH/Bureau of Narcotic Enforcement Riverview Center 150 Broadway Albany NY 12204 866-811-7957 Option 1 DOH-4329 7/12. Official New York State Prescription Registration Form NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Narcotic Enforcement Section 21 of the Public Health Law requires all prescriptions both for controlled substances and non-controlled substances written in New York State be issued on an Official New York State Prescription form* A practitioner must first register with the Department of Health to receive their official prescriptions free of charge. Per Part 910 of 10 NYCRR a practitioner s registration shall be valid for a period of two years. NEW Registration complete and sign this form and the Prescription Order Form to obtain free Official New York State Prescriptions. RENEWAL Registration complete and sign this form and return prior to the last day of the month in which your registration expires. NOTE Drug Enforcement Administration DEA Numbers If you have a DEA your prescriptions may only be shipped to your DEA address and this address will be imprinted on your prescriptions. If you need to change your DEA registered address contact the DEA at 877-883-5789 or on-line www. deadiversion*usdoj. gov* Obtain confirmation of updated DEA address and then submit a copy of your revised DEA registration with this application form* If you do not have a DEA you are required to have your Affirmation notarized* Please submit completed Acknowledgement section below. Your prescriptions will be shipped to your Primary Practice Office address and this address will be imprinted on your prescriptions. APPLICANT S NAME LAST FIRST MI PROFESSION NYS LICENSE NUMBER DEA REGISTRATION NUMBER If applicable NPI NUMBER INDIVIDUAL ADDRESS IF DEA REGISTERED - Enter address as it appears on your DEA registration* IF NON-DEA REGISTERED - Enter address of your Primary Practice Office. CITY STATE ZIPCODE NY IMPORTANT Please include your most recent fax number and/or business email address for Bureau communications. PHONE NUMBER FAX NUMBER Area Code - APPLICANT S BUSINESS E-MAIL ADDRESS AFFIRMATION FOR ALL PRACTITIONERS Under penalty of perjury I affirm that the statements herein are true. Original Ink Only DATE// PRINT NAME ACKNOWLEDGEMENT FOR PRACTITIONERS WITHOUT DEA NUMBERS Notary signature and stamp required ss On the day of in the year before me the undersigned personally appeared personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity that by his/her signature on the instrument the individual executed the instrument and that such individual made such appearance before the undersigned in the city of State of. Official New York State Prescription Registration Form NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Narcotic Enforcement Section 21 of the Public Health Law requires all prescriptions both for controlled substances and non-controlled substances written in New York State be issued on an Official New York State Prescription form* A practitioner must first register with the Department of Health to receive their official prescriptions free of charge. Per Part 910 of 10 NYCRR a practitioner s registration shall be valid for a period of two years. NEW Registration complete and sign this form and the Prescription Order Form to obtain free Official New York State Prescriptions. .