Get Audrey Clark, Mpa, Director, Office Of Controlled Substances Administration - Dhmh Maryland

This guide provides clear instructions on how to complete the Audrey Clark, MPA, Director, Office of Controlled Substances Administration form online. By following these steps, users can ensure their application is filled out accurately and completely.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the establishment name or 'doing business as' (dba) in the corresponding field. Make sure that the name is accurate and reflects the legal name of the establishment.
3. Provide the complete address, including street address, city, state, and zip code of your establishment in the designated fields.
4. Enter the telephone number and fax number of your establishment. Ensure these numbers are correct for any necessary communication.
5. Input the Maryland CDS registration number along with its expiration date. This number is critical for the legitimacy of your application.
6. Record the Maryland pharmacy/distributor permit number and its expiration date, if applicable.
7. Document the resident state license or permit number and its expiration date. This is necessary for regulatory compliance.
8. Enter the DEA registration number and its expiration date to verify lawful drug handling.
9. Specify the hours of operation for your establishment, detailing days from Monday to Sunday.
10. Identify the person responsible for accountability of controlled dangerous substances (CDS) at your establishment, including their job title and/or educational qualifications.
11. Provide a brief description of the type of work conducted involving CDS. Ensure that this description is clear and concise.
12. List the schedules of CDS that are shipped or delivered to establishments or patients in Maryland (e.g., CI, CII, CIII, CIV, CV). Be precise in your responses.
13. Provide the names, addresses, and phone numbers of all Maryland establishments that purchase or take possession of CDS from your establishment, if applicable.
14. Describe the secure procedures employed for the delivery and receipt of CDS to Maryland establishments or patients.
15. List all licenses, permits, and registrations issued by your state’s regulatory agencies pertaining to CDS. Be sure to include the date and findings of the most recent inspection.
16. Review your form to ensure that all questions have been answered completely. Incomplete applications may result in processing delays.
17. Sign and date the application. Print the name of the applicant in the designated space below the signature.
18. Once completed, ensure that any changes are saved, and proceed to download, print, or share the form as required.

Complete your application online today to ensure a smooth processing experience.