The Texas Nar 115 form is a crucial document used for the modification of registration under the Texas Controlled Substances Act. This form allows Emergency Medical Services (EMS) providers to update essential information regarding their medical director and business address, ensuring compliance with state regulations. Completing the Nar 115 accurately is vital for maintaining the integrity of EMS operations in Texas.
The Texas Nar 115 form is an essential document for Emergency Medical Services (EMS) providers seeking to modify their registration under the Texas Controlled Substances Act. This form captures critical information about the EMS organization, including details about the current and new medical director, such as names, degrees, and license numbers. It also requires the EMS business address, which must not be a P.O. Box. The form includes sections for drug schedules, allowing the organization to specify which categories of controlled substances they will handle. Signatures from both the medical director and EMS administrator are necessary to validate the information provided. By signing, applicants certify that all details are accurate and grant permission for inspections as mandated by the law. Proper completion and submission of the Nar 115 form is crucial for compliance and continued operation within the state's regulatory framework.
Modification of Registration-EMS
under
Texas Controlled Substances Act
EMS Registration Information
___________________
______________________
DPS Number
DEA Number
DSHS Board License Number
Old Information(Medical Director)
______________________________________________________________________________________
Name (Last, First, Middle)
Degree
TX Medical Board # Personal DPS Number
_________________________________________________________________
EMS Business Address
City, State, Zip
New Information(Medical Director)
Name (Last, First, Middle)Degree TX Medical Board # Personal DPS Number
EMS Business Address (Cannot accept a PO Box number only)
Drug Schedules (Check all applicable) (2) Schedule II
(2N) Schedule II-Non-Narcotic
(3) Schedule III
(3N) Schedule III-Non-Narcotic
(4) Schedule IV
(5) Schedule V
Signature
__________________________
(
)_____________
_____________________
Signature of Medical Director
Phone Number
Date
Signature of EMS Admin.
Notice: Signature of applicants certifies that the above information is current and correct. Signature of applicant further grants the director or his designee the right to inspect controlled premises or records to be kept by the Texas Controlled Substances Act of 1973.
Return to: Controlled Substances Registration MSC-0438, PO Box 4087, Austin, Texas, 78773-0438 Or fax to 512/424-5799
NAR-115 (5/10)
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