Prescription Authorization Form
Prior to shipping prescription products (pharmaceuticals and/or medical devices), we must have authorization from the physician
(Medical Director) responsible for your department. Please fill in your customer information below, have your authorizing physician
complete the box below, and send this completed form to us by email, fax or mail along with copies of all requested licenses. If your
agency does not have a Medical Director, but is licensed to purchase prescription products, please send us a copy of all applicable
licenses along with this form for our review.
To purchase controlled substances, we must also have a copy of your agency’s Federal DEA license (Form 223) and State issued
controlled substance license (if applicable). Please note that controlled substances can only ship to the address listed on the Federal
DEA license submitted.
Schedule II controlled substances require an original, completed, and signed Federal DEA Form 222 sent each time an order is placed
and, the physical copy must be received before the order may be filled. Please call for information about completing this form properly.
Customer Number (if known): _______________________________________________________________________________________
Customer Name: ___________________________________________________________________________________________________
Contact Person: _________________________________________ E-Mail: ___________________________________________________
Telephone Number: ____________________________________ Fax Number: _____________________________________________
Shipping Address: __________________________________________________________________________________________________
City: ___________________________________________ State: _____________________________ Zip: ____________________________
Additional Shipping Locations?______
If allowing medications to be shipped to multiple addresses initial here & attach list of approved locations.
Customer License Information (must attach copies of all applicable licenses):
State EMS or Pharmacy License Number & Exp. Date: ____________________________________________________________
State Controlled Substance License & Exp. Date: ________________________________________________________________
Federal DEA License & Expiration Date: _________________________________________________________________________
* THIS SECTION TO BE COMPLETED BY MEDICAL DIRECTOR*
Please check one of the four categories below denoting your level of authorization for the purchase of devices and
medications for the above facility; include additional information and approvals where necessary.
Medical Device Authorization Only. Absolutely No Medications!
Limited Authorization for the following Medications and Medical Devices Only: List below or attach sheet if necessary
Unlimited Medications and Medical Devices Authorization. Absolutely No Controlled Substances!
Unlimited Medications, Controlled Substances, and Medical Devices: Please initial all approved controlled substances
Schedule III, IV, & V Controlled Substance Authorization of: (please initial each approved medication
_______ Ketamine (Schedule III) _______
Other(s) (list here):
Schedule II Controlled Substance Authorization of: (please initial each approved medication
Other(s) (list here): ______________________________________
By signing below, I hereby authorize the internally-designated representative(s) of this facility to order the above approved
devices and/or medications (please send copy of physician’s license with this form).
Physician Name (please print):
Medical License# & Exp. Date:
If any change occurs in the above information (including authorizations, license information, and/or authorizing physician) a new
Prescription Drug Authorization Form must be submitted with applicable licenses before any additional shipments may be processed.
Southeastern Emergency Equipment
P.O. Box 1097
Youngsville, NC 27596