Example DEA Form-222

This is an interactive form FOR ILLUSTRATIVE PURPOSE ONLY

  • Hover over the numbers for detailed instructions
  • Click anywhere on the form to see a list of meds to select from
  • Close the window to populate the form

Please PRINT CLEARLY and LEGIBLY. Do not correct any typos or mistakes. You must start over.

BEFORE SENDING TO MPS: Fax, email or text an image of the completed form to your Account Manager. This will allow us to review your form for any errors before you spend your time and money to send out the form.
When ready, make a photocopy of the form for your records and mail the original to:
MEDICAL PURCHASING SOLUTIONS, LLC, 15021 N. 74TH STREET SUITE #300, SCOTTSDALE, AZ 85260
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DEA FORM-222 U.S. OFFICIAL ORDER FORMS - SCHEDULES I & II
DRUG ENFORCEMENT ADMINISTRATION 		OMB APPROVAL No. 1117-0010
PURCHASER INFORMATION

Dr Name
Business Name
Street Address
City, State, Zip 		REGISTRATION INFORMATION

REGISTRATION #:
REGISTERED AS:
SCHEDULES:
ORDER FORM NUMBER:
DATE ISSUES:
SUPPLIER DEA NUMBER:#
                 
PART 2: TO BE FILLED IN BY PURCHASER
MEDICAL PURCHASING SOLUTIONS, LLC
BUSINESS NAME
15021 N. 74TH STREET SUITE #300
STREET ADDRRESS
SCOTTSDALE, AZ 85260
CITY, STATE, ZIP CODE
PART 1: TO BE FILLED IN BY PURCHASER
(Physician's Name)
Print or Type Name and Title
(Physician's Signature)
Signature of Requesting Official (must be authorized to sign order form)
 9/10/2024
Date
PART 5:
TO BE
FILLED IN BY
PURCHASER
PART 3: ALTERNATE SUPPLIER IDENTIFICATION - to be filled in by first supplier
(name in part 2) if order is endorsed to another supplier to fill.
ALTERNATE DEA #
                 
Signature - by first supplier.
 
OFFICIAL AUTHORIZED TO EXECUTE ON BEHALF OF SUPPLIER
 
DATE
ITEM NO. OF
PACKAGES		 PACKAGE
SIZE		 NAME OF ITEM NUMBER REC'D DATE
REC'D		 PART 4: TO BE FILLED IN BY SUPPLIER
NATIONAL DRUG CODE		 NUMBER
SHIPPED		 DATE
SHIPPED
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0 ← LAST LINE COMPLETED (MUST BE 20 OR LESS)
Remember to make a photocopy of the form for your records before you mail the original to us.

Requirements for a properly completed DEA Form-222

  • The registrant name & address must be exactly the same as the address on your current DEA Certificate.
  • DO NOT fill out the SUPPLIERS DEA REGISTRATION NO., NATIONAL DRUG CODE, NUMBER SHIPPED or DATE SHIPPED fields.
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Name of Supplier: Medical Purchasing Solutions, LLC
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Street Address: 15021 N. 74TH STREET SUITE #300
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City, State and Zip: SCOTTSDALE, AZ 85260
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Name of Physician or Power of Attorney:
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Signature of Physician or Power of Attorney*: Unsigned forms cannot be processed. *If the signature is anyone other than the Physician, we must have a copy of the Power of Attorney in our files.
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Date: Today’s Date (the date you are filling out the form)
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Number of Packages: The quantity of the drug being ordered
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Size of Package: The size of the drug being ordered (ie. 20ml, 10x5ml)
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Name of Item: The name and description/strength of the drug being ordered (ie. Fentanyl vial, Fentanyl amps, Demerol 50mg/ml)
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Last Line Completed: This number should correspond to the Line No. of the last line on which a product was ordered.