Controlled Substance Registration DEPARTMENT OF HEALTH Licensure and Certification 615 East 4th Street Pierre, SD 57501-1700 605-773-3356 FAX: 605-773-6667 July 1, 2009 $150.00 FEE REQUIRED ­ INSTRUCTIONS on REVERSE FEE MUST ACCOMPANY APPLICATION or RENEWAL APPLICANT NAME BUSINESS NAME BUSINESS ADDRESS BUSINESS PHONE EMAIL ADDRESS SD PROFESSIONAL LICENSE# MAILING ADDRESS (if different from business address) FAX NUMBER DEA# EXP. DATE (attach photo copy of certificate) PROFESSIONAL BUSINESS ACTIVITY (Check the appropriate box) Dentist Medical Doctor Schedule I Optometrist Osteopathic Doctor Schedule II Schedule II Non-narcotic Pharmacy Veterinarian Podiatrist DRUG SCHEDULES (Check the appropriate box) Schedule III Schedule III Non-narcotic Schedule IV ALL APPLICANTS MUST ANSWER THE FOLLOWING: Has the applicant or any officer or partner been Has the applicant or any officer or partner convicted of a felony under state or federal law surrendered any previous registration or relating to the manufacture, distribution, or professional license or had any previous dispensing of controlled substances? registration or professional license, state federal, revoked, suspended, or denied? (write "yes" or "no") (write "yes" or "no") or If you have answered "yes" to either statement, please attach a notarized statement showing details. I hereby apply for my South Dakota Controlled Substance Registration in accordance with South Dakota Codified Law 3420B. Signature______________________________________________Date__________________________ Every person who prescribes manufactures, distributes, or dispenses any controlled drug or substance within this state, or who proposes to engage in the prescribing manufacture, distribution, or dispensing of any controlled drug or substance within this state, shall obtain annually a registration issued by the department according to the rules promulgated under this chapter. (SDCL 34:20B:29) The department is authorized to inspect the establishment of a registrant or applicant for registration in accordance with the rules promulgated under this chapter. (SDCL 34:20B:40) OFFICE USE ONLY Approval Referred to DEA Date CS # Issued Fee Check# American LegalNet, Inc. www.FormsWorkFlow.com SD Controlled Substance # Issued Expiration Date SOUTH DAKOTA CONTROLLED SUBSTANCE REGISTRATION INSTRUCTIONS 1. Fee required (ARSD 44:58:03:02.1) $150 fee required for initial application and renewal. Fee must accompany application. Fee is non-refundable and not pro-rated. Make check, money order, or cashier's check payable to the South Dakota Department of Health. $75 fee for locum tenens physicians. 2. Read the statement of South Dakota Codified law (SDCL34:20B:29 and SDCL 34:20B:40) found at the bottom of the application. 3. The name and address of the proposed business or professional office in South Dakota must be included on your application. A street address or legal description, rather than a post office box number is required. Include your mailing address as well as your business, home and fax phone numbers. 4. Indicate your South Dakota professional license number. Pharmacies should indicate the license number issued by the South Dakota Board of Pharmacy. If your professional license had not been issued by your respective licensing board, write "pending". 5. Indicate your federal DEA number. If you have applied for a DEA number but it has not been issued, write "pending". DEA numbers are location specific, but can be transferred, by notifying the DEA office and the SD Department of Health. Attach a photocopy of your DEA certificate to the application. If you are completing a renewal application: Enclose a photocopy of your NEW DEA certificate, not the one currently expiring. You may hold your renewal until you receive your certificate from the DEA or attach a copy of your DEA renewal application. 6. Indicate the profession, discipline or business activity for which you are requesting registration. 7. Indicate the schedules of controlled substances for which you are requesting registration. Your federal registration must coincide with the schedules you request on your state registration. All controlled substances listed in federal schedule V are included in SD schedule IV. 8. Answer the questions regarding previous felony convictions or surrender of professional license or controlled substance registration. If you answer "yes" to either question, attach a notarized statement explaining the details. 9. Date and sign the application. 10. Each location where you dispense or administer controlled substances requires separate registration. Prescribing at more than one location is permissible under a single registration. 11. If you have any questions, please call the Department of Health at (605) 773-3356. 12. Forms should be mailed to: Licensure and Certification, Department of Health, 615 E 4th Street, Pierre, SD 57501-1700. American LegalNet, Inc. www.FormsWorkFlow.com