DOH 4329 Form PDF Details

In New York State, the regulation of prescriptions is enhanced by the requirement that all such documents, whether for controlled or non-controlled substances, be issued on an Official New York State Prescription form, as underscored by Section 281 of the NYS Public Health Law (PHL). The DOH 4329 form plays a central role in this process, providing a means for practitioners to register or renew their registration with the Department of Health, thereby enabling them to issue official prescriptions. The Bureau of Narcotic Enforcement oversees this registration, which is valid for two years and mandates not only the completion of the DOH 4329 form but also the registration of e-prescribing systems. A noteworthy requirement for practitioners with a DEA number is that prescriptions can only be dispatched to the address registered with the DEA, underscoring the tight integration between state and federal regulatory frameworks. Moreover, for those without a DEA number, an affirmation needs to be notarized to complete the registration process. This setup ensures that every practitioner issuing prescriptions in New York adheres to a standardized protocol, ultimately aiming to enhance patient safety and regulatory compliance.

QuestionAnswer
Form Name DOH 4329 Form
Form Length 2 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 30 sec
Other names Electronic Prescribing - New York State Department of Health - NY.gov

Form Preview Example

NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Narcotic Enforcement

Official New York State Prescription Registration

Section 281 of the NYS Public Health Law (PHL) requires all prescriptions (both for controlled substances and non-controlled substances) written in New York State be issued on an Official New York State Prescription form. This PHL requires that practitioners renew their registration and register their e-prescribing systems with the Department. A practitioner must first register with the Department of Health to receive their official prescriptions free of charge. Per Part 910 of Title 10 NYCRR, a practitioner’s registration shall be valid for a period of two years.

NEW Registration, complete and sign this form and the Prescription Order Form to obtain the Official New York State Prescriptions.

RENEWAL Registration, complete and sign this form and return prior to the last day of the month in which your registration expires.

NOTE: Drug Enforcement Administration (DEA) Numbers

If you have a DEA #, your prescriptions may only be shipped to your DEA address and this address will be imprinted on your prescriptions. If you need to change your DEA registered address, contact the DEA at 877-883-5789 or on-line at www.deadiversion.usdoj.gov. Obtain confirmation of updated DEA address and then submit a copy of your revised DEA registration with this application form.

If you do not have a DEA #, you are required to have your Affirmation notarized. Please submit completed Acknowledgement section below. Your prescriptions will be shipped to your Primary Practice Office address and this address will be imprinted on your prescriptions.

AN INCOMPLETE FORM WILL NOT BE PROCESSED

Practitioner’s Name

Last

 

 

First

Profession

 

 

Specialty [see back]

NYS License Number

 

 

 

DEA Registration Number [if applicable]

 

 

NPI Number [Individual] [if applicable]

 

 

 

MI

Physician Assistant must attach a completed DOH-5054 form

(https://www.health.ny.gov/forms/doh-5054.pdf).

Practitioner’s Address

[If DEA registered, enter address as it appears on your DEA registration. If Non-DEA Registered, enter address of your primary practice office.]

Street

City

 

 

 

 

 

 

 

 

 

 

 

State NY

Zip Code

–

Practitioner’s Contact Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[Please include your fax number, Practitioner’s contact and business e-mail addresses for Bureau communications.]

 

 

Phone Number (

)

 

 

 

–

 

Fax Number (

)

 

 

–

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Practitioner’s Contact E-Mail Address

 

 

 

 

 

 

@

 

 

 

 

 

Practitioner’s Business E-Mail Address

 

 

 

 

 

 

@

 

 

 

 

 

AFFIRMATION FOR ALL PRACTITIONERS

Under penalty of perjury, I affirm that the statements herein are true.

Signature (Original Ink Only)

 

 

 

 

 

Date

Print Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACKNOWLEDGEMENT FOR PRACTITIONERS WITHOUT DEA NUMBERS (Notary signature and stamp required)

ss: On the

 

 

day of

, in the year

before me, the undersigned,

 

 

 

personally appeared

 

 

 

,

 

 

 

personally known to me or proved to me on the basis of satisfactory evidence to be the individual

 

 

 

whose name is subscribed to the within instrument and acknowledged to me that he/she executed

the same in his/her capacity, that by his/her signature on the instrument,

 

 

 

the individual executed the instrument, and that such individual made such appearance before the

undersigned in the City of

 

 

 

, State of

.

 

 

PLEASE MAIL COMPLETED FORM(S) TO ADDRESS BELOW

NYSDOH/Bureau of Narcotic Enforcement

Official Prescription Program – Registration Unit

Riverview Center

150Broadway Albany, NY 12204

You may fax or e-mail completed forms to: 518-402-1058 or narcotic@health.ny.gov

For more information, call 866-811-7957

DOH-4329 (9/21) p 1 of 2

SPECIALTIES

 

Aerospace

Orthodonture

Allergy/Immunology

Orthopedic Surgery

Anesthesiology

Osteopathic Manipulative Medicine (Omm)

Cardiology

Otolaryngology

Cardiovascular Disease

Parenteral Conscious Sedation (Dentist)

Child Neurology

Pathology (Anatomic And Clinical)

Child Psychiatry

Pathology (Anatomic)

Clinical Pathology

Pathology (Blood Bank)

Colon And Rectal Surgery

Pathology (Chemical Pathology)

Dental Anesthesiologist

Pathology (Dermatopathology)

Dermatology

Pathology (Hematology)

Dermatopathology

Pathology (Neuropathology)

Diagnostic And Roentgenology (Competence Nuclear Radiology)

Pediatric Allergy

Diagnostic Radiology

Pediatric Cardiology

Emergency Medicine

Pediatric Critical Care

Endodontist

Pediatric Endocrinology

Family Practice

Pediatric Gastroenterology

Forensic Pathology

Pediatric Hematology Oncology

General Dentist

Pediatric Infectious Disease

General Preventive Medicine

Pediatric Neonatal -Perinatal Medicine

General Surgery

Pediatric Nephrology

Gynecologic Oncology

Pediatric Otolaryngology

Hemodialysis

Pediatric Pulmonology

Hospitalist

Pediatric Surgery

Internal Medicine

Pediatrics

Medical Genetics

Pedodontist

Medical Microbiology

Periodontist

Medical Oncology

Physical Medicine And Rehabilitation

Medicine (Endocrinology)

Plastic Surgery

Medicine (Gastroenterology)

Preventive Aerospace Medicine

Medicine (Hematology)

Preventive Occupational Medicine

Medicine (Infectious Diseases)

Preventive Public Health

Medicine (Nephrology)

Prosthodontist

Medicine (Pulmonary Diseases)

Psychiatry (Not Child)

Medicine (Rheumatology)

Psychiatry And Neurology

Neurological Surgery

Public Health Dentist

Neurology (Not Child)

Radioisotopic Pathology

Neuromusculoskeletal Medicine & Omm

Radiologist Oncology

Nuclear Medicine

Radiology

Obstetrics And Gynecology

Radiology (Medical Nuclear Physics)

Obstetrics And Gynecology (Maternal - Fetal Medicine)

Therapeutic Radiology

Obstetrics And Gynecology (Reproductive Endocrinology)

Thoracic Surgery

Opthalmology

Urology

Oral Pathologist

Veterinarian

Oral Surgeon

Other Specialty

DOH-4329 (9/21) p 2 of 2

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Filling out segment 1 of Doh 4329 Form

2. Soon after this section is filled out, go on to type in the relevant details in these: Practitioners Contact Information, Phone Number, Fax Number, Practitioners Contact EMail Address, Practitioners Business EMail, AFFIRMATION FOR ALL PRACTITIONERS, Under penalty of perjury I affirm, Signature Original Ink Only, Print Name, Date, ACKNOWLEDGEMENT FOR PRACTITIONERS, ss On the day of in the year, PLEASE MAIL COMPLETED FORMS TO, and NYSDOHBureau of Narcotic.

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