Form MO580-3012 "Mid-level Practitioner Application for a Missouri Controlled Substances Registration and Practitioner Availability Census" - Missouri

Form MO580-3012 is a Missouri Department of Health and Senior Services form also known as the "Mid-level Practitioner Application For A Missouri Controlled Substances Registration And Practitioner Availability Census". The latest edition of the form was released in February 1, 2017 and is available for digital filing.

Download a PDF version of the Form MO580-3012 down below or find it on Missouri Department of Health and Senior Services Forms website.

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Download Form MO580-3012 "Mid-level Practitioner Application for a Missouri Controlled Substances Registration and Practitioner Availability Census" - 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. Only the practitioner may complete
the application and it cannot be delegated.
(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.
AN EqUAL OPPORTUNiTy / AFFiRMATivE ACTiON EMPLOyER: Services provided on a nondiscriminatory basis.
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. Only the practitioner may complete
the application and it cannot be delegated.
(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.
AN EqUAL OPPORTUNiTy / AFFiRMATivE ACTiON EMPLOyER: Services provided on a nondiscriminatory basis.
INSTRUCTIONS FOR COMPLETING MID-LEvEL PRACTITIONER 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.
Fields on the application that are required to obtain a controlled substances registration are marked with an asterisk(*). There are other
questions on the application that are voluntary for the purposes of taking a census to determine practitioner availability and shortage areas in
Missouri. Please be sure to write legibly.
*(1)
Provide your full legal name. This will be printed on your registration. The name on this registration and the federal DEA registration
must match.
*(2)
indicate if this is your first Missouri Controlled Substances Registration ever or provide your previous/existing registration number if you
have had a previous registration.
*(3)
A social security number is required pursuant to Section 454.403, RSMo. Applicants are also required to submit their date of birth
(MM/DD/yyyy).
*(4)
indicate if you hold a current professional license, the type of license and the license number. Also indicate if your professional license
is pending. it is possible that some researchers may not have a professional license. Name the agency or state board that issued the
license. if your are licensed to practice in other states, indicate the names of the states.
(5)
identify your primary specialty group, primary specialty and certification status. identify secondary and tertiary specialties also.
*(6)
indicate your gender, race and ethnicity. As part of the voluntary census, we ask that you indicate what language(s) you speak fluently.
(7)
Provide your current email address where the Bureau of Narcotics and Dangerous Drugs may contact you or send information.
*(8)
Provide your current DEA number, if you have one. if you do not have one, leave this blank or write in the word “pending.”
*(9)
indicate the controlled substance schedules for which you are requesting authority. A complete listing of drugs by name and schedule
appear on the BNDD’s website www.health.mo.gov/BNDD under the link to publications.
*(10) if you have any collaborative or supervision agreements pursuant to Chapter 334, RSMo, provide a list of the names, license numbers
and expiration dates of each of the mid-level practitioners with which you have an agreement.
*(11) Provide your principle and primary practice location where this registration may be issued. This must be a Missouri practice location where
patient care occurs and controlled substance activities take place. it must be a physical street address and not a PO Box or mailing address.
This should be the location where the practitioner spends the most time. This principle address is what appears on the drug registration
certificate. it must match the federal DEA certificate address. Provide the business telephone number and fax machine number for this location.
*(12) Provide a breakdown of the work hours you practice each week. if you have secondary practice locations, please provide the address of the
secondary locations and the number of hours at those secondary locations. Additional sheets may be attached if necessary.
(13) indicate the practice setting for the primary location and any type of obligations at that location. For census purposes, the department
would like to know if you offer services at a reduced rate, if you accept Medicaid and if you accept new patients.
(14) you may provide a separate mailing address if you want your mail sent to a different location than your practice address. This mailing
address may be a PO Box. This mailing address must be in the United States.
*(15) Provide information on any guilty pleas entered for any controlled drug violations, regardless of what sentence was finally imposed. This
includes guilty pleas and suspended sentences. Please indicate whether this information is already on file with the Bureau. if a waiver is
required, the employer must obtain a waiver before allowing an employee with guilty pleas or convictions to have any access to controlled drugs.
*(16) Provide information on any public disciplines, restrictions, probations, surrenders, or revocations taken by administrative regulatory
agencies on either your professional license or your state or federal controlled substance registrations. indicate if any such regulatory
discipline is in process or pending.
*(17) Section 195.040.2, RSMo states that no registration may be issued to any person who is abusing controlled substances. indicate
whether the applicant is abusing or has abused or been treated for or diagnosed with addiction regarding controlled substances during
the past year. For purposes of this subsection, “abusing” or “abused” means using or having used a controlled substance in a manner
not authorized under Chapter 195, RSMo.
(18) This field provides instructions on the amount fees that must be paid and how to pay the fees. Fees are $30 for an annual registration.
An additional late fee of $10 is required if the practitioner has expired and lapsed in registration for a period greater than 15 calendar
days. No fee is required if the practitioner is employed by a government agency. The applicant claiming exemption must name the
government agency. This free registration is restricted to the registrant’s government work only. if the registrant wants to practice in the
private sector, the registrant must pay a fee for a registration.
(19) This field provides information on how paper applications are to be mailed or delivered to the department.
*(20) Applicants are required to manually sign and date an application that is submitted on paper.
MiSSOURi DEPARTMENT OF HEALTH AND SENiOR SERviCES
BUREAU OF NARCOTiCS AND DANGEROUS DRUGS
MID-LEvEL PRACTITIONER APPLICATION FOR A MISSOURI CONTROLLED
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SUBSTANCES REGISTRATION AND PRACTITIONER AvAILABILITy CENSUS
PLEASE USE THE ATTACHED INSTRUCTIONS THAT APPEAR wITH THIS FORM. (*) REqUIRES A RESPONSE.
*1.  yOUR LEGAL NAME
LAST NAME
FiRST NAME
MiDDLE NAME
SUFFix
*2. 
PREviOUS BNDD# iF yOU HAvE BEEN PREviOUSLy REGiSTERED
First Time Registration
*3.  SOCiAL SECURiTy NUMBER (REqUiRED By SECTiON 454.403, RSMO)
*DATE OF BiRTH (MM/DD/yy)
TyPE OF BUSINESS ACTIvITy - MID-LEvEL PRACTITIONER
*4.  PROFESSiONAL LiCENSE NUMBER
or
License is pending
Advanced Practice Nurse     
Physician’s Assistant     
Assistant Physician
NAME OF STATE LiCENSiNG AGENCy OR BOARD
OTHER STATES yOU ARE LiCENSED iN
5.  APRNs PRIMARy SPECIALTy GROUP
Acute Care
Administration
Adult Health
Adult Psych / Mental Health
Cardiac Nursing
Case Management
Child / AdolescentPsych / Mental Health
Community Health
Consultant
Diabetes Management
Education
Family Health
General Nursing
Gerontological Nursing
Home Health
infection Control
informatics
Medical-Surgical
Neonatal
Occupational / industrial Health
Oncology
Other ______________________________
Pain Management
Patient Care
Pediatric
Public Health
quality Assurance
Research
School Nursing
Utilization Review
Women’s Health
PRIMARy CERTIFICATION
Board Eligible
Board Certified
Not Applicable
SECONDARy SPECiALTy
SECONDARy CERTiFiCATiON STATUS
TERTiARy SPECiALTy
TERTiARy CERTiFiCATiON STATUS
MO 580-3012 (2-17)
PAGE 1
*6. GENDER
Male     
Female
*RACE (CHECk ONE)
Caucasian
African-American
Asian indian
American indian
Alaskan Native
Chinese
Filipino
Guamanian
Chamorro
Japanese
korean
Native Hawaiian
Other Asian
Other Pacific islander
Samoan
Multiracial/Other
*ETHNiCiTy (CHECk ONE)
Cuban
Mexic
an
Mexican-American
Chicano
Non-Hispanic
Other Hispanic/Latino
Spanish
Puerto Rican
FLUENT LANGUAGES (MAy CHECk MULTiPLE)
English
Spanish or Spanish Creole
German
French (incl. Patois & Cajun)
Chinese
vietnamese
Serbo-Croatian
italian
Russian
Arabic
korean
Tagalog
African Languages
Other West Germanic
*8. DEA NUMBER (iF APPLiCABLE)
7. EMAiL ADDRESS
*9. CONTROLLED SUBSTANCE SCHEDULES REqUESTED
Schedule ii
Schedule iii — (testosterone, acetaminophen/codeine)
Schedule iv — (benzodiazepines, alprazolam, diazepam)
Schedule v — (diphenoxylate, pregablin)
*10. Please list the name(s) of physician(s) you have agreements with:
NAME(S)
MD OR DO
LICENSE #
ExPIRATION DATE
MO 580-3012 (2-17)
PAGE 2
*11. PRIMARy PRACTICE LOCATION (Must be a physical Missouri address where patient care occurs and controlled drug activity takes
place. This must be your principle location where you spend the most time.)
STREET ADDRESS
CiTy
STATE
ziP CODE
COUNTy
BUSiNESS PHONE NUMBER
BUSiNESS FAx NUMBER
*12. PLEASE PROviDE THE NUMBER OF HOURS yOU WORk/PRACTiCE EACH WEEk iN THE SPACES BELOW
_______ Direct patient care (non-hospital)
_______ inpatient hospital care
_______ Administration
_______ Research
_______ Teaching
_______ Other
*If you have secondary practice locations, please submit the information for Sections 11 & 12 above for each additional location.
you may staple these additional sheets and location information to this application.
13. PRACTICE SETTING TyPE
Community Health Center
Correctional Facility
Free Clinic
Group Health Plan (HMO)
Hospital
Military facility or other federal facility
University Hospital
Nursing Home/LTCF
Other State Facility
Private Office
Public Health
School of Medicine
OBLiGATiON TyPES
J-1 viSA
National Health Service Corps
National interest Waiver
None
State Loan Repayment
DO yOU PERFORM SERviCES AT A REDUCED RATE, USiNG A SLiDiNG FEE SCALE, FOR iNDiviDUALS WiTH qUALiFyiNG iNCOMES?
yes     
No
DO yOU ACCEPT MEDiCAiD?
DO yOU ACCEPT NEW PATiENTS?
yes     
No
yes     
No
14. 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
*15. 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?
yes     
No      If no, please provide the required information with this application.
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
MO 580-3012 (2-17)
PAGE 3
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