DEA DESIGNATION FORM

DEA DESIGNATION FORM
Provider name: Provider First Name* Provider Last Name* NPI: *
Name of Facility*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Administrator*

First NameLast Name
Administrator Contact*
Format: (000) 000-0000.
If you are required to submit a DEA number and you do not have one, you must take the following action:

Select one of the following reasons and complete any blanks:
Option 1* I am currently working on obtaining a DEA license (it is in process or is still pending) – I have elected Provider First Name* Provider Last Name* as a temporary alternate prescriber to write prescriptions for controlled substances on my behalf until I have a valid certification. Their DEA number is DEA Number*.
Option 2* I elect not to prescribe controlled substances myself but have identified First Name* Last Name* to write these prescriptions on my behalf. Their DEA number is DEA Number*.
Option 3* I elect not to prescribe controlled substances myself but have identified Facility Name* to write these prescriptions on my behalf. Their DEA number is DEA Number*.
Option 4* I do not prescribe controlled substances for my patients. If I determine that a patient may require a controlled substance, I refer the patient to their PCP or to another practitioner for evaluation and management.
Physician Full Name Name*

First NameLast Name
Physician Signature*

Clear
Signature Date*

MonthDayYear
Date
Should be Empty:

Option 2* I elect not to prescribe controlled substances myself but have identified First Name* Last Name* to write these prescriptions on my behalf. Their DEA number is DEA Number*.