Form Dhec 1199 PDF Details

Are you an employer or a business owner in South Carolina and looking for more information about Form DHEC 1199? You’ve come to the right place! In this blog post, we will provide background context on Form DHEC 1199, explain what it is, who must complete it, when it needs to be completed by and include links to helpful resources. Read on if you are interested in learning more about how this important form affects businesses in the state of 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)

How to Edit Form Dhec 1199 Online for Free

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It is simple to complete the document following our detailed guide! This is what you need to do:

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)

It's very easy to get it wrong when completing your Signature, consequently ensure that you take another look before you send it in.

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