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Ny. gov with Certification in the subject line. Or mail to NYS Bureau of Narcotic Enforcement OPP Registration Unit Riverview Center 150 Broadway Albany NY 12204 FAX 518-402-1058 DOH-5221 6/16 Date. NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Narcotic Enforcement Practitioner Certification Form - Electronic Prescribing Pursuant to 281 7 of the Public Health Law a practitioner shall not be required to issue prescriptions electronically if he or she certifies to the Department in a manner specified by the Department that he or she will not issue more than twenty-five prescriptions during a twelve-month period. Prescriptions in both oral and written form for both controlled substances and non-controlled substances are included in determining whether the practitioner will reach the limit of twenty-five prescriptions. A certification is valid for one year. Should the practitioner exceed twenty-five prescriptions within the twelve-month period he or she is required to issue prescriptions electronically or obtain from the Department a waiver from the requirement to electronically prescribe. Complete Sections I through III. I. PRACTITIONER INFORMATION - Please Print Legibly Practitioner Name License Email Contact Phone Profession Mailing Address STREET CITY STATE ZIP I certify during the twelve-month period beginning on MM/DD/YYYY I will not issue more than twenty-five prescriptions. I will count prescriptions in both oral and written form for both controlled and non-controlled substances toward my limit of twenty-five prescriptions. False statements made herein are punishable as a class A misdemeanor pursuant to 210. 45 of the Penal Law. Practitioner Signature Print Name III. SUBMIT CERTIFICATION Please email the completed form to narcotic health. NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Narcotic Enforcement Practitioner Certification Form - Electronic Prescribing Pursuant to 281 7 of the Public Health Law a practitioner shall not be required to issue prescriptions electronically if he or she certifies to the Department in a manner specified by the Department that he or she will not issue more than twenty-five prescriptions during a twelve-month period. Prescriptions in both oral and written form for both controlled substances and non-controlled substances are included in determining whether the practitioner will reach the limit of twenty-five prescriptions. Prescriptions in both oral and written form for both controlled substances and non-controlled substances are included in determining whether the practitioner will reach the limit of twenty-five prescriptions. A certification is valid for one year. Should the practitioner exceed twenty-five prescriptions within the twelve-month period he or she is required to issue prescriptions electronically or obtain from the Department a waiver from the requirement to electronically prescribe. A certification is valid for one year. Should the practitioner exceed twenty-five prescriptions within the twelve-month period he or she is required to issue prescriptions electronically or obtain from the Department a waiver from the requirement to electronically prescribe. Complete Sections I through III. I. PRACTITIONER INFORMATION - Please Print Legibly Practitioner Name License Email Contact Phone Profession Mailing Address STREET CITY STATE ZIP I certify during the twelve-month period beginning on MM/DD/YYYY I will not issue more than twenty-five prescriptions.

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