Form DOH-3827 "Application to Be a Controlled Substance Agent for an Als Agency" - New York

What Is Form DOH-3827?

This is a legal form that was released by the New York State Department of Health - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2015;
  • The latest edition provided by the New York State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DOH-3827 by clicking the link below or browse more documents and templates provided by the New York State Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form DOH-3827 "Application to Be a Controlled Substance Agent for an Als Agency" - New York

Download PDF

Fill PDF online

Rate (4.8 / 5) 93 votes
Page background image
NEW YORK STATE DEPARTMENT OF HEALTH
Application to be a Controlled Substance
Bureau of Emergency Medical Services and Trauma Systems
Agent for an ALS Agency
Bureau of Narcotic Enforcement
Submit Application and all Required Attachments in Triplicate. Print or type neatly. Incomplete Applications will be Returned.
Initial
Renewal
03C-
Exp
NYS EMS Agency Code
NYS EMS Cert. Expiration
NYS Controlled Substance License
Agency Name
Federal Employer Number
Email
Physical Address of Principle Business (street and number)
City
State
Zip
County
( ) -
Ambulance ALS First Responder
Mailing Address (PO Box)
Business Phone
Service Type
Agency CEO/COO
Name
Title
Business Address
City, Town, Village
State
Zip
( ) -
( ) -
Mailing Address (PO Box)
Business Phone
Home Phone
Controlled Substance Agent
Name
NYS EMT No. and Level (CC or P) NYS EMT Expiration Date
Pharmacist Lic. No.
Street Address
City, Town, Village
State
Zip
( ) -
Mailing Address (PO Box)
Best Phone H/W/C
E-mail
Medical Directors Affirmation
I have read and understand the content of 80.136 and agree to act as the agency’s Medical Director. I understand my responsibilities relative to this
application and hereby approve this agency’s use of controlled substances under my medical direction.
Name of Physician Medical Director
Signature of Physician Medical Director
Date
Part 80 Controlled Substances Applicant Certification
By Signing this application I certify that:
1. I have read and understand the contents and responsibilities of public Health Law Articles 30 and 33, the State EMS code (10NYCRR (art. 800)
and Controlled Substances Regulations (10NYCRR Part80)
2. All information is correct and true
3. I or any named owner or responsible individual under the provisions of this part have never been convicted of a felony.
4. I accept the responsibilities as provided in 80.136(k)
5. I will insure all provisions and requirement s of the part are understood ad implemented by any person under my charge.
6. I will instruct all persons under my charge with their responsibilities with regard to storage, access, safeguarding of controlled substances and
the reporting of any misuse or diversion.
7. I understand that any misrepresentation or falsification of this application is grounds for annulment, suspension, limiting or revocation of this
article 33 license and may make me and the EMS Agency subject to further action by the New York State Department of Health.
Name of Agency CEO/COO
Signature of CEO/COO
Date
Name of Agent
Signature of Agent
Date
Notary Public
For DOH Use Only
Affirmation and Acknowledgement for Agent
EMS
Approved
Date
BCS
Approved
Date
Send completed application to:
New York State Department of Health
Telephone 518-402-0996
Bureau of Emergency Medical Services and Trauma Systems
875 Central Avenue, Albany, NY 12206
DOH-3827 (7/15)
NEW YORK STATE DEPARTMENT OF HEALTH
Application to be a Controlled Substance
Bureau of Emergency Medical Services and Trauma Systems
Agent for an ALS Agency
Bureau of Narcotic Enforcement
Submit Application and all Required Attachments in Triplicate. Print or type neatly. Incomplete Applications will be Returned.
Initial
Renewal
03C-
Exp
NYS EMS Agency Code
NYS EMS Cert. Expiration
NYS Controlled Substance License
Agency Name
Federal Employer Number
Email
Physical Address of Principle Business (street and number)
City
State
Zip
County
( ) -
Ambulance ALS First Responder
Mailing Address (PO Box)
Business Phone
Service Type
Agency CEO/COO
Name
Title
Business Address
City, Town, Village
State
Zip
( ) -
( ) -
Mailing Address (PO Box)
Business Phone
Home Phone
Controlled Substance Agent
Name
NYS EMT No. and Level (CC or P) NYS EMT Expiration Date
Pharmacist Lic. No.
Street Address
City, Town, Village
State
Zip
( ) -
Mailing Address (PO Box)
Best Phone H/W/C
E-mail
Medical Directors Affirmation
I have read and understand the content of 80.136 and agree to act as the agency’s Medical Director. I understand my responsibilities relative to this
application and hereby approve this agency’s use of controlled substances under my medical direction.
Name of Physician Medical Director
Signature of Physician Medical Director
Date
Part 80 Controlled Substances Applicant Certification
By Signing this application I certify that:
1. I have read and understand the contents and responsibilities of public Health Law Articles 30 and 33, the State EMS code (10NYCRR (art. 800)
and Controlled Substances Regulations (10NYCRR Part80)
2. All information is correct and true
3. I or any named owner or responsible individual under the provisions of this part have never been convicted of a felony.
4. I accept the responsibilities as provided in 80.136(k)
5. I will insure all provisions and requirement s of the part are understood ad implemented by any person under my charge.
6. I will instruct all persons under my charge with their responsibilities with regard to storage, access, safeguarding of controlled substances and
the reporting of any misuse or diversion.
7. I understand that any misrepresentation or falsification of this application is grounds for annulment, suspension, limiting or revocation of this
article 33 license and may make me and the EMS Agency subject to further action by the New York State Department of Health.
Name of Agency CEO/COO
Signature of CEO/COO
Date
Name of Agent
Signature of Agent
Date
Notary Public
For DOH Use Only
Affirmation and Acknowledgement for Agent
EMS
Approved
Date
BCS
Approved
Date
Send completed application to:
New York State Department of Health
Telephone 518-402-0996
Bureau of Emergency Medical Services and Trauma Systems
875 Central Avenue, Albany, NY 12206
DOH-3827 (7/15)