NOTE: Remove the right edge of the form along the perforation and mail us the top two copies (Brown & Green) including the carbon. Retain the bottom copy (Blue) for your records.
Requirements for a properly completed DEA Form-222
The DEA requires that the registrant name & address be exactly the same as the address on your current DEA Certificate.
DO NOT fill out the SUPPLIERS DEA REGISTRATION No., National Drug Code, Packages Shipped or Date Shipped fields.
Those fields will be completed by Medical Purchasing Solutions.
1
Name of Supplier: Medical Purchasing Solutions, LLC
2
Street Address: 15021 N. 74th Street #300
3
City and State: Scottsdale, AZ 85260
4
Date: Today’s Date (the date you are filling out the form)
5
Number of Packages: The quantity of the drug being ordered
6
Size of Package: The size of the drug being ordered (ie. 20ml, 10x5ml)
7
Name of Item: The name and description/strength of the drug being ordered (ie. Fentanyl vial, Fentanyl amps, Demerol 50mg/ml)
8
Last Line Completed: This number should correspond to the Line No. of the last line on which a product was ordered.
9
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.