Get Mo 580-3014 2021-2025

The MO 580-3014 form is essential for practitioners seeking a Missouri Controlled Substances Registration. This guide provides clear, step-by-step instructions to assist users in accurately completing the form online to ensure prompt processing.

Follow the steps to successfully complete the MO 580-3014 form online.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter your full legal name in the designated fields. Ensure the name matches the one on your federal DEA registration.
3. Fill in your social security number and date of birth in the specified formats to meet regulatory requirements.
4. Select your professional license status, including the type of license and licensing agency, if applicable.
5. Identify your primary specialty and any secondary specialties, including your certification status.
6. Indicate your gender, race, and ethnicity as part of the voluntary census information.
7. Provide your current email address for communication regarding your application.
8. Input your DEA number if you currently have one, or write ‘pending’ if you do not.
9. Request the specific controlled substance schedules for which you are seeking authority.
10. Specify your anticipated controlled drug activities at your primary practice location.
11. If applicable, list any collaborative or supervisory agreements with mid-level practitioners.
12. Enter the physical address of your primary practice location, including business phone and fax numbers.
13. Detail your weekly work hours in patient care, administrative tasks, and other relevant activities.
14. Describe your practice setting type and obligations, including accepting Medicaid and new patients.
15. If necessary, provide a separate mailing address for correspondence.
16. Answer questions related to criminal history concerning controlled substance violations.
17. Disclose any administrative license discipline history that may affect your application.
18. Indicate whether you have abused or been treated for addiction relating to controlled substances in the past year.
19. Submit payment details for the required registration fees and identify any applicable exemptions.
20. Follow the outlined instructions for mailing or delivering your completed application.
21. Sign and date the application, ensuring all required fields are complete to avoid processing delays.
22. Once completed, you can save, download, print, or share the form as needed.

Complete the MO 580-3014 online to secure your Missouri Controlled Substances Registration today.