Get Mo 580-3014 2017-2026

Filling out the MO 580-3014 form for Missouri Controlled Substances Registration is crucial for practitioners engaging in controlled substance activities. This guide provides a step-by-step approach to completing the application accurately, ensuring all necessary information is included.

Follow the steps to complete your application effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Start by providing your full legal name in the designated fields. Ensure that the name matches exactly as it will be printed on your registration.
3. Enter your social security number and date of birth in the specified format (MM/DD/yyyy). Both fields are required.
4. Indicate whether this is your first application for a Missouri Controlled Substances Registration. If previously registered, provide your previous registration number.
5. In the professional license section, indicate whether you hold a current professional license, specify the type and number, and identify the licensing agency.
6. Select your primary specialty and provide information about any secondary and tertiary specialties, as well as your certification status.
7. Indicate your gender, race, and ethnicity. These fields are part of a voluntary census, so you may choose not to respond.
8. Provide a current email address for communication regarding your application.
9. List the controlled substance schedules you are requesting authority for, using the complete listing from the Bureau's publication.
10. If applicable, enter your DEA number. If you do not have a DEA number, either leave it blank or write ‘pending.’
11. Describe the anticipated controlled drug activity at your primary location, choosing from the options provided.
12. If you have any collaborative agreements with mid-level practitioners, provide their names, license numbers, and expiration dates.
13. Specify your primary practice location, including the full physical address, business phone number, and fax number.
14. Detail your weekly work hours in patient care, research, or other activities. You can attach additional sheets if necessary.
15. Indicate the practice setting type and any obligations at that location, such as whether you accept Medicaid or new patients.
16. If you wish to provide a different mailing address, enter the required information.
17. Disclose any histories of criminal activity or administrative discipline relating to your professional license as required.
18. Affirm whether you have abused controlled substances or received treatment for such issues in the past year.
19. Review the fee structure for the application and ensure payment is included as specified.
20. Mail or deliver your completed application along with attachments to the addresses provided in the instructions.
21. Finally, manually sign and date your application, confirming the accuracy of the information provided.

Complete your MO 580-3014 application online to ensure a smooth registration process.