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Narcotic Enforcement Forms

Official Prescription Program

• Official New York State Prescription Registration Form (DOH-4329) (PDF, 38KB, 1pg.)
• New York State Official Prescription Order Form (DOH-250) (PDF, 17KB, 1pg.)
• Pharmacy Request for a Follow-up Prescription (DOH-4358) (PDF, 21KB, 1pg.)
• Register and Order Official Prescriptions Free of Charge
• Notification of Loss/Theft of Official New York State Prescriptions (DOH-4387) (PDF, 21KB, 1pg.)

Narcotic Enforcement

• Request for Approval to Conduct a Medication Collection Event-Controlled Substances (DOH-4446) (PDF, 25KB, 1pg.)
• Request for Approval of On-Site Destruction of Controlled Substances (DOH-2340) (PDF, 54KB, 1pg.)
  • Instructions for Request for Approval of On-Site Destruction of Controlled Substances (PDF, 65KB, 1pg.)
• Reverse Distributor List (Surrender to Independent Companies)
• Controlled Substance Inventory Form (DOH-166) (PDF, 77KB, 1pg.)
• Methadone Usage Summary Report (DOH-4334) (PDF, 12KB, 1pg.)
• Loss of Controlled Substances Report (DOH-2094) (PDF, 54KB, 2pg.)

Controlled Substance Licensing and Certification Forms

• License Application to Engage in a Controlled Substance Activity (DOH-4330) (PDF, 36KB, 2pg.)
  • Instructions to Apply for a License to Engage in a Controlled Substance Activity (PDF, 69KB, 6pg.)
• Application for Registration of an Incorporated Society or Municipal Animal Control Facility to Euthanize Animals (DOH-4333) (PDF, 21KB, 1pg.)
• Application for Certification as Euthanasia Technician for Animals (DOH-4332) (PDF, 22KB, 1pg.)
• Euthanasia Technician Statement of Employer (DOH-2165) (PDF, 15KB, 1pg.)
• Controlled Substances Semi-Annual Report for EMS Agencies (DOH-3848) (PDF, 629KB, 1pg.)
• Application for ALS Agency to Engage in Controlled Substances Activity for Pre-Hospital Care (DOH-3826) (PDF, 1.5MB, 2pg.)
• Quarterly Controlled Substances Inventory Form for Humane Societies (DOH-4331) (PDF, 33KB, 1pg.)
• Certificate of Need to Possess Hypodermic Syringes and Needles (DOH-2278) (PDF, 15KB, 2pg.)
• Application for Registration for Expanded Syringe Access Demonstration Program (ESAP) (PDF, 40KB, 2pg.)

These forms are also available by sending a request to:

Bureau of Narcotic Enforcement
433 River Street
Suite 303
Troy, NY 12180
Phone: (866) 811-7957
E-mail: narcotic@health.state.ny.us