Get Mo 580-3012 2017-2025

Completing the MO 580-3012 form online is a straightforward process that requires careful attention to detail. This guide is designed to help you navigate each section of the application to ensure accurate and timely submission.

Follow the steps to successfully complete your application.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by providing your full legal name as it will appear on your registration. Ensure that the name matches with your federal DEA registration.
3. Enter your social security number and date of birth in the specified format (MM/DD/yyyy).
4. Indicate whether this is your first application for a Missouri Controlled Substances Registration or provide your previous registration number if applicable.
5. List your current professional license type, number, and specify if it is pending. Include the agency or state board that issued your license.
6. Identify your primary specialty group, primary specialty, and certification status. Provide secondary and tertiary specialties as required.
7. Fill out the demographic information including gender, race, and ethnicity. You may voluntarily indicate the languages you speak fluently.
8. Provide your email address for communication from the Bureau of Narcotics and Dangerous Drugs.
9. If applicable, input your DEA number. If you do not hold one, leave this field blank or write 'pending'.
10. Indicate the controlled substance schedules for which you are requesting authority, and attach a list of substances as needed.
11. Submit the names, license numbers, and expiration dates of any collaborative or supervisory agreements you have.
12. Provide your principal practice location’s physical address in Missouri, including street address, city, state, and business phone number.
13. Break down your work hours each week at the primary and any secondary practice locations.
14. Select your practice setting type and any obligations you may have at this location. Indicate if you offer services at a reduced rate, accept Medicaid, or will take new patients.
15. If you wish to have your mail sent to a different address, provide a separate mailing address.
16. Disclose any criminal history regarding controlled substances, if applicable, and confirm if the information is already on file with the Bureau.
17. Indicate if there are any administrative disciplinary actions against your professional licenses and if they are pending.
18. Respond to inquiries about the unauthorized use or abuse of controlled substances in the past year.
19. Make a payment of the applicable fees, detailing how you plan to pay.
20. Follow the instructions for mailing or delivering your completed application to the appropriate address.
21. Sign and date your application, ensuring that all required fields marked with an asterisk are completed.
22. Review your application for completeness and clarity before submitting it.

Complete your documents online to ensure a smooth registration process.