Form Dhec 1199 PDF Details

Whenever professionals with a South Carolina Controlled Substances Registration find themselves on the move, the DHEC 1199 form becomes an indispensable tool for ensuring their ability to continue their practice without interruption. Managed by the South Carolina Department of Health and Environmental Control's Bureau of Drug Control, this form streamlines the process of changing the address associated with one's controlled substances registration. It requires thorough completion, demanding details such as both the existing and new addresses, the SC Controlled Substances Registration Number, Federal DEA Registration Number, and, if applicable, the new supervising physician for Advanced Practice Registered Nurses (APRNs) and Physician Assistants (PAs). The latter group also benefits from a section dedicated to updating supervising physician details. The importance of signing the form and retaining a copy for personal records cannot be overstated, as these steps are crucial for a smooth transition. Given the potential for delays in processing due to incomplete information, this form serves as a critical nexus in upholding the regulatory compliance and operational fluidity of healthcare professionals within South Carolina.

QuestionAnswer
Form NameForm Dhec 1199
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesD 1199 dhec form 222

Form Preview Example

SCDHEC-Bureau of Drug Control

2600 Bull Street

Columbia, SC 29201

Phone: 803-896-0634

ADDRESS CHANGE REQUEST

An address change on a current SC Controlled Substances Registration can be made on this form. Complete the form below in its entirety. Once completed, sign the form, make a copy for your records, and mail or fax this form to SCDHEC-Bureau of Drug Control, 2600 Bull Street, Columbia, SC 29201, (Fax) 803-896-0627. Failure to include the required information may result in a delay in the change request.

SC Controlled Substances Registration Number:

Federal DEA Registration Number:

Registrant’s Name:

Address Listed on Current Certiicate:

New Address:

(Practice Location Only)

New Supervising Physician (APRN’s & PA’s Only)

Printed Name/Signature of Physician not required

New Telephone Number:

Relocation Date:

* Last 4 digits of FEIN# or Social Security#

Signature:Date:

(Signature of the Registrant is required to process this form.)

*Required for on-line renewal process in the future.

DHEC 1199 (03/2014)

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1. For starters, when filling in the Form Dhec 1199, start in the form section that includes the subsequent blanks:

Filling out segment 1 in Form Dhec 1199

2. Now that this array of fields is completed, you should insert the required details in Last digits of FEIN or Social, Signature, Date, Signature of the Registrant is, Required for online renewal, and DHEC so that you can move forward to the 3rd part.

Form Dhec 1199 completion process detailed (step 2)

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