Form Lara Hid 220 – Fill Out and Use This PDF

The LARA/ HI D-220 form is a critical document from the Michigan Department of Licensing and Regulatory Affairs that is used to record and report the dispensation of controlled substances through the Michigan Automated Prescription System (MAPS). This requirement, set by Board of Pharmacy Rule 338.3162d, mandates that dispensers complete and submit this form within 7 calendar days after a controlled substance has been dispensed. For individuals and healthcare providers needing to comply with these regulations, detailed instructions on filling out the form are available by clicking the button below.

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Form Lara Hid 220 PDF Details

In an effort to regulate and monitor the dispensation of controlled substances, the State of Michigan’s Department of Licensing and Regulatory Affairs has implemented a critical tool: the LARA/HI D-220 form, under the purview of the Michigan Automated Prescription System (MAPS). This form plays a fundamental role in combating the misuse and abuse of prescription drugs, ensuring that every dispensed controlled substance is accounted for. It entails detailed sections for both dispenser and patient information, including the dispenser's DEA number, and for patients, involves a thorough capture of personal details and the specifics of the controlled substance dispensed - from the drug name to the quantity and mode of payment. Noteworthy is the form's inclusiveness, accommodating information if the patient happens to be a veterinary one, hence enhancing its utility across a broader spectrum of the healthcare industry. The necessity for this form is underscored by Board of Pharmacy Rule 338.3162d, mandating its completion and submission within a stringent timeline post-dispensation, emphasizing the state’s commitment to diligent oversight and patient safety. Additionally, the directive encapsulates the state’s stance on non-discrimination and accessibility, ensuring equitable treatment and support for all individuals, including those with disabilities, underlining the form’s role not just as a regulatory requirement, but as a testament to ethical healthcare practices.

Question	Answer
Form Name	Form Lara Hid 220
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	cis_fhs_bhser_m apsclaimform4 09_316533_7 what is maps claim form in michigan

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LARA/ HI D-220 (02/ 14)

State of Michigan

Department of Licensing and Regulatory Affairs

Bureau of Health Care Services

Michigan Aut omat ed Prescript ion Syst em ( MAPS)

P.O. Box 30454, Lansing, Michigan 48909

Telephone: (517) 373-1737 Fax: (517) 241-5072 E-Mail: BHCSMAPSI nfo@michigan.gov

Website: www.michigan.gov/ mimapsinfo

MAPS CLAI M FORM

Authority: P.A. 231 of 2001

Board of Pharmacy Rule 338.3162d requires this form to be completed for every controlled substance that is dispensed, and mailed or delivered to MAPS no later than 7 calendar days after the date the controlled substance has been dispensed.

Dispenser I nformat ion ( Please Print )

DEA Number	Dispenser’s First Name			Middle Name	Last Name

Street Address			City			State	Zip Code

Telephone Number with Area Code		Email Address

Pat ient I nformat ion (I f veterinary patient – use pet owner information)

Customer I D (Driver’s License or State I D Number)

Patient’s First Name (human)

Last Name

Street Address

City

State

Zip Code

Date of Birth (human)

Sex

Species Code

Male

Female

Unknown

Human

Veterinary Patient

Cont rolled Subst ance Dispensed

I ssued Date

Filled Date

Prescriber DEA Number

NDC Number (Must be eleven digits)

Drug Name

-–

Quantity

Refill Number

Transmission Form

Written Prescription

Telephone

Telephone Emergency

Fax

Days Supply

Authorized Refills

Mode of Payment

Private Pay

Medicaid

Medicare

Commercial I nsurance

RX Number

Major Medical

Worker’s Comp

I ndian Nations

Other