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 do not correct any typos or mistakes. You must start over.

When you’re done, remove the right edge of the form along the perforation and mail us
the top two (Brown & Green) copies, including the carbon.
Retain the bottom (Blue) copy for your records.

IMPORTANT: DO NOT write on the envelope with the form inside. Doing so will ruin the form and it will be rejected.

1
2
3
4
5
6
7
8
9
See Reverse of PURCHASER'S
Copy for Instrustions		 No order from may be issued for Schedule I and II substances unless a
completed application form has been received, (21 CFR 1305.04)		 OMB APPROVAL
No. 1117-0010
TO: (Name of Supplier)
MEDICAL PURCHASING SOLUTIONS, LLC		 STREET ADDRESS
15021 N. 74th STREET #300
CITY and STATE
SCOTTSDALE, AZ 85260 		DATE
8/22/2019
TO BE FILLED IN BY SUPPLIER
SUPPLIERS DEA REGISTRATION No.
L
I
N
E
No 		TO BE FILLED IN BY PURCHASER
No. of
Packages		 Size of
Package		 Name of Item National Drug Code Packages Shipped Date Shipped
1      
2      
3      
4      
5      
6      
7      
8      
9      
10      
0
←  LAST LINE
COMPLETED		         (MUST BE 10 OR LESS)
SIGNATURE OF PURCHASER
OR ATTORNEY OR AGENT 		                           (Doctor's Signature)
Date Issued
DEA Printed Form		 DEA Registration No.
DEA Printed Form		 Name and Address of Registrant


DEA Printed Form
Schedules
DEA Printed Form		  
Registered as a
DEA Printed Form		 No. of this Order Form
DEA Printed Form
DEA Form-222
(Oct. 1992)		 U.S. OFFICIAL ORDER FORMS - SCHEDULES I & II
DRUG ENFORCEMENT ADMINISTRATION
SUPPLIER'S Copy 1 		65692016
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.