Mid-level practitioners should use this form to update their supervising physician on file.
Signature: the signature of the registrant is required to process this form.
Relocation date: address changes will not be reflected on the registration until 10 days prior to the relocation date.
New address: practice location only.
Complete: the form must be filled out in its entirety and emailed or mailed back to the program.
Delay: failure to include the required information may result in a delay in the change request.
| Question | Answer |
|---|---|
| Form Name | Form 1199-ENG-DPH |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 15 |
| Avg. time to fill out | 3 min |
| Edition | Rev 06/2026 |
| Where to send | Mail or email the signed form to SCDPH - Bureau of Drug Control, PO Box 2046, West Columbia, SC 29033, or email to bdc@dph.sc.gov |
| Other names | 1199-ENG-DPH, 1199, Form 1199-ENG-DPH, SC 1199, South Carolina Controlled Substances Registration Address Change Request |
| Official source | Form 1199-ENG-DPH (Rev 06/2026), South Carolina Department of Public Health |
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