Controlled Substance Prescribing Authorization Change Request Form
Submit this form to request changes to controlled substance prescribing authorizations. Please complete all sections accurately.
Requestor Full Name
*
First Name
Last Name
Requestor Email Address
*
example@example.com
Requestor Role or Title
*
Department or Practice
*
Provider Name (if different from requestor)
Current Authorization Details
*
Requested Authorization Change
*
Effective Date of Requested Change
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Change
*
Additional Comments or Notes
Submit Change Request
Should be Empty: