Access request form 2026

1. Click ‘Get Form’ to open the access request form in the editor.
2. Begin by entering your full name in the designated field. Ensure you include your first name, middle initial, last name, and any suffix (e.g., Jr., Sr.).
3. Fill in your Social Security Number (SSN) and Date of Birth (DOB) accurately to avoid processing delays.
4. Select your Professional Title from the provided options such as RPH, MD, DO, etc.
5. Input your State Board License Number along with its expiration date. Similarly, provide your DEA Number and its expiration date.
6. Enter your email address and facility details including name, address, city/county, state/zip code.
7. Provide a valid phone number and fax number for communication purposes.
8. Create a proposed password that meets the specified criteria: at least 8 characters with a mix of uppercase letters, lowercase letters, and numbers.
9. Sign the form where indicated as Prescriber/Dispenser's Signature. Ensure this is done in front of a Notary Public for validation.
10. Finally, review all entries for accuracy before submitting the notarized form along with required documents to the ASBP Controlled Substances Prescription Monitoring Program.

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