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- Click ‘Get Form’ to open the doh form 2021 in the editor.
- Begin by entering your name in the designated fields: Last, First, and Middle Initial. Ensure accuracy as this information is crucial for your registration.
- Fill in your profession and New York State license number. If applicable, include your DEA registration number and NPI number.
- Provide your address as it appears on your DEA registration if you are DEA registered. Otherwise, enter the address of your Primary Practice Office.
- Include your city, state (NY), and zip code. Don’t forget to add a fax number and/or business email for communications from the Bureau.
- Sign the affirmation section under penalty of perjury, ensuring that you use original ink only. Include the date of signing.
- If you do not have a DEA number, complete the acknowledgment section requiring notarization before submission.
- Once completed, save your document and follow instructions to mail it to the provided address; faxes are not accepted.
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