1086 03/11New York State Department of Health • Bureau of Narcotic Enforcementwww.health.ny.gov/professionals/narcotic/

RPH ADD WITH

Practitioner Authorization

RPH ADD WITHOUT

Practitioner Authorization

NEVER ADD

RPH CHANGE WITH Practitioner

Authorization

RPH CHANGE WITHOUT

Practitioner Authorization

NEVER CHANGE

Practitioner DEA#

Patient Address

Patient Name

Practitioner DEA#

Patient Address

Patient Name

Institutional DEA #/suffix Patient Sex

Practitioner Signature

Institutional DEA #/suffix Patient Sex

Practitioner Signature

Directions Patient AgeDate Written Directions Patient Age

Date Written

Code Drug Name Code Drug Name

MDD Quantity Quantity

Strength MDD

Strength

Dosage Form

Pharmacist’s Add/Change Reference for Controlled Substance Prescriptions

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