580-3014 (8-2021) PRACTITIONER APPLICATION FOR A MISSOURI CONTROLLED SUBSTANCES REGISTRATION AND PRA-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your full legal name in the designated fields. Ensure that this matches your federal DEA registration.
3. Indicate whether this is your first application or provide your previous registration number if applicable.
4. Fill in your social security number and date of birth as required by state law.
5. Provide details about your professional license, including type and issuing agency. If licensed in other states, list those as well.
6. Complete the sections regarding your primary specialty, gender, race, and ethnicity. This information helps with census data collection.
7. Enter your current email address for communication from the Bureau of Narcotics and Dangerous Drugs.
8. Specify the controlled substance schedules you are requesting authority for and describe your anticipated drug activity at your primary location.
9. Provide information on any collaborative agreements with mid-level practitioners if applicable.
10. Finally, review all entries for accuracy before signing and submitting the application to avoid processing delays.

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