Form Doh 250 PDF Details

Form Doh 250 is a term you may have heard tossed around the office, but what exactly does it mean? It is an IRS form used to report the receipt of any foreign contribution or donation above $250.00. This form helps ensure that all donations are accounted for and reported in order to avoid any legal trouble. Any individual or organization receiving a donation over this amount must submit a Form Doh 250 within 15 days of receipt. So what do you do if you receive a foreign donation? Simply gather all the information pertaining to the donation and complete Form Doh 250. Not sure where to start? Check out our guide on How to Complete Form Doh 250 below!

QuestionAnswer
Form NameForm Doh 250
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesRx, deadiversion, Radiosotopic, New_York

Form Preview Example

 

NEW YORK STATE DEPARTMENT OF HEALTH

 

 

 

 

 

 

 

Official Prescription Program

 

BUREAU OF NARCOTIC ENFORCEMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Order Form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete items 1-6. An incomplete form may result in the delay of your order. Order only up

 

 

 

 

 

 

 

PHYSICIAN’S SPECIALITY CODES

 

 

 

to a 1-month supply of Official Prescriptions .

 

 

 

 

 

 

 

 

 

 

 

 

 

Please identify the specialty that most closely describes your practice and enter the three-digit code on the prescription

 

 

To receive Official Prescriptions free of charge, you must be registered with the Official

 

 

order form in the space provided at left. If you are unable to identify your practice with one of the specialties listed, please

 

 

Prescription Program.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

enter Code 600 and identify in writing the nature of your practice.

 

 

 

Forward Order Form to: Standard Register

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Official Prescription Program

 

 

 

 

ALLERGY

010

UROLOGY

230

 

 

 

 

 

631 Industrial Blvd.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANESTHESIOLOGY

020

EMERGENCY MEDICINE

250

 

 

 

 

 

P.O Box 1130

 

 

 

 

 

 

 

 

 

 

 

 

 

COLON AND RECTAL SURGERY

030

PATHOLOGY (Medical Microbiology)

139

 

 

 

 

Toccoa, GA 30577

 

 

 

 

 

 

 

 

 

 

 

 

 

DERMATOLOGY

040

PATHOLOGY (Neuropathology)

141

 

 

If you have questions, call 1-866-772-4683.

 

 

 

 

 

 

 

 

 

 

 

 

 

DERMATOPATHOLOGY

041

PATHOLOGY (Pathologic Anatomy)

142

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FAMILY PRACTICE

050

PATHOLOGY (Dermalopathology)

143

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICINE

060

PATHOLOGY (Anatomical & clinical)

146

1.

NYS LICENSE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICINE (Cardiovasc. Disease)

061

PATHOLOGY (Radiosotopic)

148

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICINE (Medical Oncology)

062

PEDIATRICS

150

2.

DRUG ENFORCEMENT ADMINISTRATION (DEA) NUMBER

 

 

 

 

MEDICINE (Endocrinology)

063

PEDIATRIC CARDIOLOGY

151

 

 

 

 

MEDICINE (Gastroenterology)

064

PEDIATRIC HEMATOLOGY ONCOLOGY

152

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICINE (Hematology)

065

PEDIATRIC NEPHROLOGY

153

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICINE (Infectious Disease)

066

NEONATAL – PERINATAL MEDICINE

154

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICINE (Nephrology)

067

PEDIATRIC ENDOCRINOLOGY

155

 

 

DEA Registered Address - Prescriptions can only be printed and shipped to the address

MEDICINE (Pulmonary Disease)

068

PHYSICAL MEDICINE & REHABILITATION

160

 

 

MEDICINE (Rheumatology)

069

PLASTIC SURGERY

170

 

 

printed on your Drug Enforcement Administration (DEA) Registration.

 

 

 

 

NEUROLOGICAL SURGERY

070

PREVENTIVE MEDICINE (Aerospace)

181

 

 

If a practitioner does not have a DEA registration, prescriptions can only be printed and

 

 

NUCLEAR MEDICINE

080

PREVENTIVE MEDICINE (General)

182

 

 

shipped to the address which is listed on a notarized registration form.

 

OBSTETRICS & GYNECOLOGY

090

PREVENTIVE MEDICINE (Occupational)

183

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OBSTETRICS & GYNECOLOGY

 

PREVENTIVE MEDICINE (Public Health)

184

 

 

Name_______________________________________________________________

 

(Gynecologic Oncology)

091

PSYCHIATRY & NEUROLOGY (Child Psych)

191

 

 

OBSTETRICS & GYNECOLOGY

 

PSYCHIATRY & NEUROLOGY (Psychiatry)

192

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEA Registered Address:_______________________________________________

 

(Maternal - Fetal Medicine)

092

PSYCHIATRY & NEUROLOGY (Neurology with

 

 

 

OBSTETRICS & GYNECOLOGY

 

Special Competence in Child Neurology)

193

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_______________________________________________

 

(Reproductive Endocrinology)

093

PSYCHIATRY & NEUROLOGY (Neurology)

194

 

 

 

 

OPHTHALMOLOGY

100

PSYCHIATRY & NEUROLOGY

195

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ORTHOPEDIC SURGERY

110

PSYCHIATRY & NEUROLOGY (Unspecified)

196

 

 

 

 

_______________________________________________

OTOLARYNGOLOGY

120

RADIOLOGY – ALL

200

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATHOLOGY (Unspecified)

130

RADIOLOGY (Diagnostic)

201

 

 

Phone Number (

 

 

 

 

 

 

 

 

)-

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

PATHOLOGY (Blood Banking)

131

RADIOLOGY (Diagnostic with Special

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATHOLOGY (Clinical Pathology)

135

Competence in Nuclear Radiology)

202

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATHOLOGY (Forensic Pathology)

136

RADIOLOGY (Therapeutic)

203

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

NUMBER OF BOOKS

1

 

 

 

 

 

5

 

 

 

 

 

10

 

 

 

 

 

 

15

 

 

20

PATHOLOGY (Hematology)

137

RADIOLOGY (Radiological Physics – All)

204

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATHOLOGY (Chem. Pathology)

138

RADIOLOGY (Therapeutic Radiological Physics)

205

 

 

(20 Book Max)

 

(100 Rx)

(500 Rx)

 

 

(1000 Rx)

(1500 Rx)

(2000 Rx)

RADIOLOGY (Radiological Physics Unspecified)

209

RADIOLOGY (Diagnostic Radiological Physics)

206

 

 

 

 

 

SURGERY

210

RADIOLOGY (Medical Nuclear Physics)

207

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SURGERY (Pediatric)

211

RADIOLOGY (Unspecified)

208

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

SPECIALTY CODE (Physician’s Only)

 

 

 

 

 

_____________________________

THORACIC SURGERY

220

OTHER (Please specify on form)

600

 

By my signature, I certify that I am registered with the DEA (if applicable) and that a current

 

 

 

 

 

 

order of the Commissioner of Health revoking or canceling use of such forms has not been

 

 

 

 

 

 

served to me.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

SIGNATURE_________________________________________ 6. DATE ____/____/____

 

******ATTENTION******

 

 

 

 

PHYSICIAN’S ASSISTANTS:

SUPERVISING M.D. INFORMATION (P.A. only)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHANGE OF ADDRESS

 

 

 

 

ORDERS MUST ALSO CONTAIN THE FOLLOWING

NAME________________________________________

 

Do not send this order until you have a new registration certificate from the DEA.

 

INFORMATION OF THE SUPERVISING M.D.:

 

 

NAME

 

 

 

 

 

DEA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LICENSE______________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LICENSE NUMBER

 

 

 

Attn: Registration Unit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEA NUMBER

 

 

 

 

 

99 10TH Avenue

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEA__________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ORDERS NOT CONTAINING THIS

 

 

 

New York, NY 10011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION WILL NOT BE PROCESSED.

 

 

 

(Contact DEA at 877-883-5789 or www.deadiversion.usdoj.gov)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Return new DEA certificate along with your Order Form and we will process your official

 

 

 

 

 

 

prescription order.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOH-250 (11/10)