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Click ‘Get Form’ to open the DEA waiver form in the editor.
Begin by filling in your personal information as a non-prescribing practitioner. Include your name, NPI, and any relevant details that explain why you do not prescribe medications.
In the designated area, provide a clear statement certifying that you will not prescribe or dispense medications. Ensure you sign and date this section.
Identify a credentialed Blue Cross Blue Shield of Massachusetts practitioner who will prescribe for your patients. Fill in their name and NPI in the appropriate fields.
If applicable, indicate if your DEA application is in process by providing the date of application and signing again. Include the name of another credentialed practitioner who will assist during this period.
Once all sections are completed, review your entries for accuracy before saving or exporting the document for submission via fax or email.

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Versions	Form popularity	Fillable & printable
2023	4.2 Satisfied (49 Votes)
2022	4.8 Satisfied (55 Votes)
2020	4.8 Satisfied (247 Votes)
2020	4.8 Satisfied (117 Votes)
2020	4.8 Satisfied (101 Votes)
2020	4.7 Satisfied (51 Votes)
2020	4.3 Satisfied (26 Votes)
2020	4.8 Satisfied (261 Votes)
2020	4.2 Satisfied (36 Votes)
2020	4.4 Satisfied (134 Votes)
2019	4.5 Satisfied (54 Votes)
2019	4.8 Satisfied (130 Votes)
2019	4.8 Satisfied (171 Votes)
2019	4.8 Satisfied (35 Votes)
2019	4.8 Satisfied (142 Votes)

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