Contents
Form Example
Modification of
under
Texas Controlled Substances Act
EMS Registration Information
___________________ |
___________________ |
______________________ |
DPS Number |
DEA Number |
DSHS Board License Number |
Old Information(Medical Director)
______________________________________________________________________________________
Name (Last, First, Middle) |
Degree |
TX Medical Board # Personal DPS Number |
_________________________________________________________________ |
||
EMS Business Address |
|
|
_________________________________________________________________
_________________________________________________________________
City, State, Zip
New Information(Medical Director)
______________________________________________________________________________________
Name (Last, First, Middle)Degree TX Medical Board # Personal DPS Number
_________________________________________________________________
EMS Business Address (Cannot accept a PO Box number only)
_________________________________________________________________
_________________________________________________________________
City, State, Zip
Drug Schedules (Check all applicable) (2) Schedule II
(2N) Schedule
(3) Schedule III
(3N) Schedule
(4) Schedule IV
(5) Schedule V
Signature
__________________________ |
( |
)_____________ |
_____________________ |
Signature of Medical Director |
Phone Number |
Date |
|
Signature |
|
|
|
__________________________ |
( |
)_____________ |
_____________________ |
Signature of EMS Admin. |
Phone Number |
Date |
|
Notice: Signature of applicants certifies that the above information is current and correct. Signature of applicant further grants the director or his designee the right to inspect controlled premises or records to be kept by the Texas Controlled Substances Act of 1973.
Return to: Controlled Substances Registration
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Common mistakes
-
Neglecting to include all required personal information: Ensure that all fields, such as your name, degree, and personal DPS number, are filled out completely. Missing any of this information can delay the processing of your application.
-
Providing an incorrect EMS business address: The form specifically states that a PO Box is not acceptable. Make sure to provide a complete street address, including city, state, and zip code.
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Failing to check the appropriate drug schedules: It’s important to check all applicable drug schedules that pertain to your registration. Not marking the correct schedules may lead to compliance issues later.
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Omitting signatures: Both the medical director and the EMS administrator must sign the form. Forgetting to include either signature can result in the rejection of your application.
-
Not providing accurate contact information: Ensure that phone numbers are correct and current. This information is crucial for any follow-up or clarification needed by the reviewing agency.
-
Submitting the form to the wrong address: Double-check that you are sending the form to the correct address listed for the Controlled Substances Registration. Sending it to the wrong location can cause significant delays.
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Ignoring the notice about inspections: Understand that by signing the application, you grant permission for inspections. Be aware of this responsibility and ensure that your premises are compliant with the Texas Controlled Substances Act.
Key takeaways
- Understand the Purpose: The Texas Nar 115 form is used to modify EMS registration under the Texas Controlled Substances Act.
- Gather Required Information: Before filling out the form, collect all necessary details including DPS number, DEA number, and DSHS board license number.
- Complete Old Information: Fill in the section for the current Medical Director, including their name, degree, and personal DPS number.
- Provide New Information: Enter the new Medical Director’s details accurately. Ensure the EMS business address is not a PO Box.
- Select Drug Schedules: Check all applicable drug schedules that the EMS is authorized to handle, from Schedule II to Schedule V.
- Signatures are Essential: Both the Medical Director and EMS Administrator must sign the form. This certifies that the information is correct and current.
- Submit Promptly: Return the completed form to the specified address or fax it to ensure timely processing of the registration modification.
Steps to Using Texas Nar 115
Completing the Texas Nar 115 form is essential for modifying your EMS registration under the Texas Controlled Substances Act. Follow these steps carefully to ensure all necessary information is accurately provided.
- Begin by filling in your EMS Registration Information. Include your DPS Number, DEA Number, and DSHS Board License Number.
- Next, provide the Old Information for the Medical Director. Write the name (Last, First, Middle), degree, TX Medical Board number, and personal DPS number.
- Enter the EMS Business Address for the old Medical Director, including the city, state, and zip code. Remember, a PO Box is not acceptable.
- Now, move on to the New Information for the Medical Director. Fill in their name (Last, First, Middle), degree, TX Medical Board number, and personal DPS number.
- Provide the EMS Business Address for the new Medical Director, again ensuring it is not a PO Box. Include the city, state, and zip code.
- Check all applicable Drug Schedules that the new Medical Director will oversee. Options include Schedule II, II-Non-Narcotic, III, III-Non-Narcotic, IV, and V.
- Sign and date the form in the designated areas for both the Medical Director and the EMS Administrator. Include their phone numbers as well.
- Review the information to ensure it is current and correct. Remember, your signature certifies this.
- Submit the completed form by mailing it to Controlled Substances Registration MSC-0438, PO Box 4087, Austin, Texas, 78773-0438, or fax it to 512/424-5799.