Narcotic Enforcement Forms
All license and registration applications are to be emailed to bnelicensing@health.ny.gov for processing. If a licensing fee is required, mail the application only (no ancillary documents), and your check to the address on the application.
Official Prescription Program
- Official New York State Prescription Registration Form (DOH-4329) (PDF)
- Official Prescription Program Order Form (DOH-250) (PDF)
- Official New York State Prescription Authorization Form for Registered Physician Assistants (RPA) (DOH-5054) (PDF)
- Notification from Pharmacy - Practitioner Failure to Provide Official Prescription (DOH-4358) (PDF)
- Register and Order Official Prescriptions Free of Charge
- Notification of Loss/Theft of Official New York State Prescriptions (DOH-4387) (PDF)
Narcotic Enforcement
- Controlled Substance Inventory for Drop Boxes in BNE Licensed Facilities (DOH-5733) (PDF)
- Application to Conduct a Pharmaceutical Collection Event (Controlled Substances) (DOH-4446) (PDF)
- Request for Approval of Disposal/Destruction of Controlled Substances (DOH-2340) (PDF)
- Reverse Distributor List (Surrender to Independent Companies)
- Controlled Substance Inventory Form (DOH-166) (PDF)
- Methadone Usage Summary Report (DOH-4334) (PDF)
- Loss of Controlled Substances Report (DOH-2094) (PDF)
Controlled Substance Licensing and Certification Forms
- Class 3A Institutional Dispenser Limited Medication Drop Box Request (DOH-5788) (PDF)
- Notification of Disciplinary Action (DOH-5723) (PDF)
- License Application and Instructions to Engage in a Controlled Substance Activite for Class 1 through 11 licenses (DOH-4330) (PDF)
- Instructions for Registrations and Certifications for Euthanasia of Animals (PDF)
- Application for Registration of an Incorporated Society or Municipal Animal Control Facility to Euthanize Animals (DOH-4333) (PDF)
- Application for Registration as a Controlled Substance Agent for a Facility Certified for Euthanasia of Animals (DOH-5273) (PDF)
- Quarterly Controlled Substances Inventory Form for Humane Societies (DOH-4331) (PDF)
- Application for Certification as Euthanasia Technician for Animals (DOH-4332) (PDF)
- Renewal Application for Certification as a Euthanasia Technician for Animals (DOH-5274) (PDF)
- Semi-Annual Controlled Substance Inventory Form for EMS Agencies (DOH-3848) (PDF)
- Application for ALS Agency to Engage in Controlled Substances Activity for Pre-Hospital Care (DOH-3826) (PDF)
- Certificate of Need to Possess Hypodermic Syringes and Needles (DOH-2278) (PDF)
- Pharmacist's Add/Change Reference for Controlled Substance Prescriptions (PDF)
- Notification from Pharmacy - Practitioner Failure to Provide Official Prescription (DOH-4358) (PDF)
- Notification of Loss/Theft of Official New York State Prescriptions (DOH-4387) (PDF)
- Loss of Controlled Subtances Report Form (DOH-2094) (PDF)
- Notification of Disposal/Destruction of Controlled Substances – Medication Drop Box (DOH-5797) (PDF)
- Controlled Substance Inventory for Drop Boxes in BNE Licensed Facilities (DOH-5733) (PDF)
- Attestation of Compliance Automated Dispensing System (DOH-5290) (PDF)
- Manufacturers and Distributors Supervisor Attestation (DOH-5794) (PDF)
These forms are also available by sending a request to:
Bureau of Narcotic EnforcementRiverview Center
150 Broadway
Albany, NY 12204
Phone: (866) 811-7957
E-mail: narcotic@health.ny.gov
