DEA License or Waiver Request

DEA License or Waiver Request
Please fill out the form below to verify your DEA information. As soon as we receive your form, we can proceed with the credentialing process.
Applicant Name*
Applicant Individual NPI (Type 1 NPI)*
Credentialing Contact Phone Number (Applicant):*
Credentialing Contact Email (Applicant):*
Specialty*
Do you hold an active DEA License?*
State(s) where I currently hold an active DEA license. (select all that apply)*
Please upload a copy of your current DEA license for the state(s) you selected.*

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Do you practice in certain states without a DEA License?*
State(s) where I currently practice, but do not hold an active DEA license. (select all that apply)*
For the state(s) where I currently practice, but do not hold an active DEA license, the following situation applies:*

I do not prescribe controlled substances and in accordance with the NCQA CVO Standards, have established an arrangement with the physician below (who has a current, unrestricted DEA License) to prescribe controlled dangerous substances on my behalf to my patients as appropriate.I do not prescribe controlled substances and in my professional judgment, the patients receiving care do not require controlled substances. My process for handling these requests is included below.
Will you be prescribing controlled substances?*

A. No, I do not prescribe controlled substances and in accordance with the NCQA CVO Standards, have established an arrangement with the physician below (who has a current, unrestricted DEA License) to prescribe controlled dangerous substances on my behalf to my patients as appropriate.B. No, I do not prescribe controlled substances and in my professional judgment, the patients receiving care do not require controlled substances. My process for handling these requests is included below.
Please upload a copy of your current DEA license.

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Prescribing Physician Name*
Prescribing Physician Email
Prescribing Physician Phone Number
Prescribing Physician NPI
Prescribing Physician DEA License #
Prescribing Physician DEA License Expiration Date

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Please share your process for handling requests to prescribe controlled substances.*
Applicant Signature*

Clear
Date*

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If you have questions, please email Andros at credentialing@andros.co or call 866-688-8881 weekdays, 9am to 6pm EST.
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