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
www.health.ny.gov/professionals/narcotic/
