Form MO580-3013 "Business Application for a Missouri Controlled Substances Registration" - Missouri

Form MO580-3013 or the "Business Application For A Missouri Controlled Substances Registration" is a form issued by the Missouri Department of Health and Senior Services.

Download a PDF version of the Form MO580-3013 down below or find it on the Missouri Department of Health and Senior Services Forms website.

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Download Form MO580-3013 "Business Application for a Missouri Controlled Substances Registration" - Missouri

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Missouri Department of Health and Senior Services
P.O. Box 570, Jefferson City, MO 65102-0570 Phone: 573-751-6400
FAX: 573-751-6010
RELAY MISSOURI for Hearing and Speech Impaired 1-800-735-2966 VOICE: 1-800-735-2466
Dear Applicant:
Attached is an application for a Missouri Controlled Substances Registration and instructions for completing the application.
Please review the instructions before completing and submitting the application.
General Information For All Applications:
(1) No controlled substance activities may take place until an application has been processed and a registration has been
issued. There are no renewals. All registrations have an expiration date or may terminate under certain conditions. No
controlled substance activities may take place until a new registration has been issued. Applications may only be completed
by the administrator, CEO, pharmacy manager, corporate officer, or a medical director for an EMS agency.
(2) A state registration from the Bureau of Narcotics and Dangerous Drugs is required prior to applying for a federal registration
from the United States Drug Enforcement Administration. Controlled substance activities may begin once both registrations
are in place. Long-term care facilities are not required to have DEA numbers. The addresses on state and federal
registrations must match.
(3) Pursuant to state regulations, all fees are processing fees and are not refundable.
(4) Checks should be made payable to the Missouri Department of Health and Senior Services.
(5) Applications and fees are processed by the Department’s Fee Receipt Unit before being forwarded to the Bureau of
Narcotics and Dangerous Drugs for processing and issuing of registrations.
(6) The Bureau no longer mails controlled substance registration certificates. Registration certificates can be verified or printed
at the Bureau’s website www.health.mo.gov/BNDD.
(7) Please review your application for completeness and accuracy before submitting it to the Department. Errors and omissions
cause delays in processing applications. Please ensure handwriting is legible.
(8) All applications submitted on paper must be mailed or delivered to the Department’s Fee Receipt Unit at the following
addresses:
Mailing address:
Hand delivery address:
Department of Health and Senior Services
Department of Health and Senior Services
Fee Receipt Unit
Fee Receipt Unit
P.O. Box 570
920 Wildwood Drive
Jefferson City, MO 65102-0570
Jefferson City, MO 65109
Bureau of Narcotics and Dangerous Drugs
P.O. Box 570
Jefferson City, MO 65102-0570
Phone: (573) 751-6321 Fax: (573) 526-2569
Website www.health.mo.gov/BNDD
www.health.mo.gov
Healthy Missourians for life.
The Missouri Department of Health and Senior Services will be the leader in promoting, protecting and partnering for health.
Missouri Department of Health and Senior Services
P.O. Box 570, Jefferson City, MO 65102-0570 Phone: 573-751-6400
FAX: 573-751-6010
RELAY MISSOURI for Hearing and Speech Impaired 1-800-735-2966 VOICE: 1-800-735-2466
Dear Applicant:
Attached is an application for a Missouri Controlled Substances Registration and instructions for completing the application.
Please review the instructions before completing and submitting the application.
General Information For All Applications:
(1) No controlled substance activities may take place until an application has been processed and a registration has been
issued. There are no renewals. All registrations have an expiration date or may terminate under certain conditions. No
controlled substance activities may take place until a new registration has been issued. Applications may only be completed
by the administrator, CEO, pharmacy manager, corporate officer, or a medical director for an EMS agency.
(2) A state registration from the Bureau of Narcotics and Dangerous Drugs is required prior to applying for a federal registration
from the United States Drug Enforcement Administration. Controlled substance activities may begin once both registrations
are in place. Long-term care facilities are not required to have DEA numbers. The addresses on state and federal
registrations must match.
(3) Pursuant to state regulations, all fees are processing fees and are not refundable.
(4) Checks should be made payable to the Missouri Department of Health and Senior Services.
(5) Applications and fees are processed by the Department’s Fee Receipt Unit before being forwarded to the Bureau of
Narcotics and Dangerous Drugs for processing and issuing of registrations.
(6) The Bureau no longer mails controlled substance registration certificates. Registration certificates can be verified or printed
at the Bureau’s website www.health.mo.gov/BNDD.
(7) Please review your application for completeness and accuracy before submitting it to the Department. Errors and omissions
cause delays in processing applications. Please ensure handwriting is legible.
(8) All applications submitted on paper must be mailed or delivered to the Department’s Fee Receipt Unit at the following
addresses:
Mailing address:
Hand delivery address:
Department of Health and Senior Services
Department of Health and Senior Services
Fee Receipt Unit
Fee Receipt Unit
P.O. Box 570
920 Wildwood Drive
Jefferson City, MO 65102-0570
Jefferson City, MO 65109
Bureau of Narcotics and Dangerous Drugs
P.O. Box 570
Jefferson City, MO 65102-0570
Phone: (573) 751-6321 Fax: (573) 526-2569
Website www.health.mo.gov/BNDD
www.health.mo.gov
Healthy Missourians for life.
The Missouri Department of Health and Senior Services will be the leader in promoting, protecting and partnering for health.
INSTRUCTIONS FOR COMPLETING BUSINESS APPLICATION
Please review these instructions as the application is completed to ensure all fields are completed correctly with the required information.
Incomplete applications cause delays in processing.
Please write legibly. Required fields are marked with an asterisk(*).
*(1)
Provide the legal business name as it shall appear on the certificate. The BNDD certificate will be issued first and the DEA registration
must match.
*(2)
Provide the d/b/a name of the business, if doing business under another name.
*(3)
Indicate if this is the first Missouri Controlled Substances Registration ever for this business or if there has ever been a previous Missouri
registration issued to the applicant for this business.
*(4)
Provide your tax ID number if you have one.
*(5)
If you are required to have a state license to conduct business, provide the license number or indicate if the license is pending. Provide
the type of license required. If no license is required to conduct business, indicate the type of registration you are applying for.
*(6)
If you are required to have a license or permit to conduct business in Missouri, identify the name of the agency issuing your license, permit
or authority to conduct business. Retail pharmacies are required to submit a “no tax due” letter from the Missouri Department of Revenue
to show the retail pharmacy is in good standing with the Missouri Department of Revenue.
(7)
Provide your business email address.
*(8)
Indicate what controlled substance schedules you are requesting authority. A complete list of drugs and schedules may be viewed at the
BNDD website www.health.mo.gov/BNDD under the link to publications.
*(9)
Provide your current DEA number if you have one. If you do not have one leave this blank or write the word “pending.” Long-term care
facilities are not required to have DEA numbers as long as they have a state registration from the BNDD.
*(10) Provide the physical street location where the registration will be issued. This must be a Missouri practice address and not a PO Box or
mailing address. The DEA registration must match this address. Provide the telephone number and a fax machine number.
(11) You may provide a separate mailing address in the USA, if you want to receive your mail at another location that is different than the
business location/practice site. This may be a PO Box. If you do not provide a separate mailing address in this field then all correspondence
will be sent to the business address.
*(12) Answer the questions pertaining to guilty pleas entered for any controlled drug violations, regardless of what sentence was finally imposed.
This includes guilty pleas for the applicant, owner, or any corporate officer of the business. The last question applies to waivers. A waiver
is needed if any employee is given access to the business’s controlled substances when that employee has had a similar guilty plea or
conviction.
*(13) Provide information on any administrative or regulatory public disciplines taken against this business’s licenses or registrations. These
would be restrictions, probations, suspensions, revocations, denials of registration or licensure at the state or federal level. Indicate if any
such type of action is pending.
(14) Section 195.040.2, RSMo states that no registration may be issued to any person who is abusing controlled substances. Indicate whether
the business owner or applicant is abusing or has abused controlled substances during the past year or if they have been diagnosed with
addiction regarding controlled substances. For purposes of this subsection, the department determines “abuse” or “abusing” by having
possessed and consumed a controlled substance in a manner not authorized by law and in violation of Chapter 195, RSMo.
(15) This field provides information on the amount fees that should be paid for different businesses. It addresses late fees for registrations that
have expired for 15 days or greater. The fee may be waived if you are a government agency and limit your controlled drug activity to your
government employment. If you practice in the private sector then you must pay a fee for a registration.
*(16) Sign and date the application. Business applications must be signed by the business owner, health facility administrator, a CEO, COO or
other corporate officer, or a board member. A pharmacist in charge may sign for a retail pharmacy. A pharmacist in charge may sign for
a retail pharmacy and the medical director signs for EMS agencies.
(17) This field is a reminder to attach any required attachments along with the completed application.
(18) This field provides information on where to mail the application and then where to address the application if it is to be hand delivered by
courier.
Please go back and review the application for completeness and accuracy. Errors and omissions in the application cause delays in processing.
Please ensure that handwriting is legible.
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
BUREAU OF NARCOTICS AND DANgEROUS DRUgS
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BUSINESS APPLICATION FOR A MISSOURI CONTROLLED SUBSTANCES REGISTRATION
PLEASE USE THE ATTACHED INSTRUCTIONS THAT APPEAR WITH THIS FORM. (*) REQUIRES A RESPONSE.
*1.  BUSINESS LEgAL NAME
*2. DOINg BUSINESS AS NAME
*3. 
PREVIOUS BNDD# IF YOU HAVE BEEN PREVIOUSLY REgISTERED
First Time Registration
*4.  MISSOURI TAx ID NUMBER (iF APPliCAble)
TYPE OF BUSINESS ACTIVITY OR LICENSE (Not all activities require a state license)
*5.  PROFESSIONAL LICENSE NUMBER
or
License is pending
LICENSE REQUIRED
Retail Pharmacy
Hospital
Emergency Medical Services
Ambulatory Surgery Center
Long Term Care Facility Emergency Kit
Long Term Care Automated Dispensing Machine
Narcotic Treatment Program
Hospice Facility
Drug Distributor
Drug Manufacturer
State Licensed Mental Health Facility
Business Researcher
LICENSE NOT REQUIRED
Drug Manufacturer (distributor’s license covers)
Drug Importer (distributor’s license covers)
Drug Exporter (distributor’s license covers)
Analytical Lab
Correctional Facilities and Jails
Teaching Institution
Other _______________________________________________________________
*6. NAME OF AGENCY ISSUING STATE LICENSE
Bureau of Health Services Regulation (Hospitals & ASCs)
Board of Pharmacy*
Bureau of Emergency Medical Services
Section for Long Term Care Regulation
Dept. of Mental Health (NTPs & Mental Health Facilities)
Bureau of Home Care & Rehabilitative Standards (Hospice)
7. EMAIL ADDRESS
*8. CONTROLLED SUBSTANCE SCHEDULES REQUESTED
Schedule I — (Researcher and Analytical Labs only)
Schedule II — (opiates, morphine, oxycodone, meperidine)
Schedule III — (acetaminophen w/codeine)
Schedule IV — (benzodiazepines, alprazolam, diazepam)
Schedule V — (diphenoxylate)
*9. DEA NUMBER IF YOU HAVE ONE
MO 580-3013 (6-16)
PAgE 1
*10. PRINCIPAL PRACTICE LOCATION (Must be the physical Missouri address where patient care occurs and controlled drug activity takes
place. it should be where the drugs are stored and dispensed and not a separate billing office location. A post office box is not allowed.)
STREET ADDRESS
CITY
STATE
zIP CODE
COUNTY
BUSINESS PHONE NUMBER
BUSINESS FAx NUMBER
11. MAILING ADDRESS (if you want your mail sent to a separate USA mailing address other than primary practice location)
STREET ADDRESS
TELEPHONE NUMBER
CITY
STATE
zIP CODE
*12. CRIMINAL HISTORY INFORMATION
This question pertains to not only criminal convictions, but also any pleas of guilty, no contest, nolo contendere, or cases where probation was
received, even if convictions were later removed. This applies to any guilty pleas for any drug offenses regardless of the final sentence or outcome.
Has the applicant or any employees of the applicant who have access to controlled substances, ever pled guilty, nolo contendere, no contest,
or otherwise ever been convicted of any violation of any state or federal law relating to controlled substances?
Yes     
No
If yes, a copy of the conviction information must be on file with the bureau. Has the information been previously submitted?
No      if no, please provide the required information with this application.
Yes     
If the applicant answered yes to the questions regarding convictions or guilty pleas, a waiver must be obtained before an employee can have
access to any controlled substances. A waiver may be applied for at the Bureau’s website www.health.mo.gov/BNDD under the link to
applications and forms. There is an application for a waiver. Has the employer already obtained a waiver for the employee at this practice location?
Yes     
No
*13. ADMINISTRATIVE LICENSURE AND REGISTRATION DISCIPLINE HISTORY
These questions apply to administrative and regulatory discipline for licenses and registrations. This question is not for criminal convictions.
Have any of the applicant’s state professional licenses, or state or federal controlled substances registrations, ever been revoked,
surrendered, suspended, restricted, or placed on probation — or has any application for a professional license or a state or federal controlled
substances registration ever been denied?
Yes     
No
If you answered yes, please attach a copy of the discipline.       
Already on file with the BNDD
Although a disciplinary action may not be finalized, is such an action pending?
Yes     
No
14. UNAUTHORIZED USE/ABUSE OF CONTROLLED SUBSTANCES
Unauthorized use and abuse of controlled substances is defined by the bureau as possessing, self-administering or ingesting a controlled
substance that was not legally obtained, possessed or authorized by a legitimate medical practitioner acting within the scope of professional
practice. All activities with controlled substances must be authorized by Chapter 195, RSMo.
During the past year, has the applicant abused or used any amount of a controlled substance?
No        (This would be controlled drugs not legally obtained or legally prescribed)
Yes     
During the past year, has the applicant been diagnosed with or received any treatment for chemical dependency or addiction relating to
controlled substances?
Yes     
No
Applicants for businesses are medical facility administrators, corporate officers, business owners, or the person signing the application.
MO 580-3013 (6-16)
PAgE 2
15. PAYMENT OF FEES
$30 for Registration
$66 for Registration
LATE FEES
Analytical Labs
Drug Manufacturer
If your prior registration expired more than15
Retail Pharmacies
Drug Distributor
days, an additional $10 late fee is required.
Hospitals
Drug Importer
Emergency Medical Services
Drug Exporter
Long Term Care Facilities
Ambulatory Surgery Centers
Narcotic Treatment Programs
Hospice Facilities
State LIcensed Mental Health Facility
These fees are for a one year registration and are processing fees that are not refundable. The fee must accompany the application. Fees
may be paid by personal or certified check, cashier’s check or money order. Checks should be made payable to the Missouri Department of
Health and Senior Services. You are exempt from paying fees if you are employed by a government agency. Having a fee exempted
registration restricts your practice to only the government employment location. If you practice with controlled substances at a non-
government location, you must obtain a separate registration and pay the appropriate fee.
Are you employed by a government agency and exempt from fees?
Yes     
No
If yes, please provide the name of the government agency: _______________________________________________________________
*16. SIGNATURE & ACKNOWLEDGEMENT
Submitting an incomplete application delays processing. Submitting false information on an applications grounds for a denial of registration
or other administrative disciplinary action pursuant to Section 195.040, RSMo. The duty and responsibility for applying for a registration
cannot be delegated. Business applications should be signed by the health facility administrator, CEO, a corporate officer, board member or
buiness owner. Medical Directors sign for EMS agencies.
PRINTED NAME OF APPLICANT
TITLE
SIgNATURE OF APPLICANT
DATE
17. REQUIRED ATTACHMENTS
Please remember to attach any required attachments.
• Copies of any previous disciplinary documents from questions 12, 13, or 14, if not already on file with BNDD.
18. MAILING INFORMATION
Applications should be mailed to the Missouri Department of Health and Senior Services, FEE RECEIPT UNIT, P.O. Box 570, Jefferson City,
MO 65102-0570.
Applications delivered by hand or by special courier should be delivered to the physical street address of the FEE RECEIPT UNIT, at the
Missouri Department of Health and Senior Services, 920 Wildwood Drive, Jefferson City, MO 65109.
MO 580-3013 (6-16)
PAgE 3
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