Controlled Substance Submissions

Welcome to the New York State Department of Health Bureau of Emergency Medical Service Controlled Substances renewal portal.

All renewal applications are due no less than 30 days prior to the expiration date of the agency’s operating certificate.  Ensure that all of the required documents are completed and uploaded in the appropriate section.

Please make sure that all corporate officers, including volunteer officers, Home addresses and telephone numbers are included.

Should you have any questions please feel free to contact your Regional Representative: https://www.health.ny.gov/professionals/ems/chart.htm

  

Submission Type
Is your agency owned by a municipality?
Name of Contact Person
Medical Director Information
Mail Check Directly to:

New York State Department of Health
Bureau of Narcotic Enforcement
Riverview Center
150 Broadway, Menands, NY 12204
 

*Under provisions of section 3305.4 of PHL municipalities operating EMS agencies are exempt from the application fee.

Include*Check must include the CS license number on the memo line or mail a copy of Page 1 of the 3826 with the check


Upload requirements
Select the storage and security to be used to safeguard the narcotics:
Upload requirements
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Include only employees/members who are authorized to administer controlled.  
DO NOT INCLUDE EMS PROVIDER DATE OF BIRTH AND SOCIAL SECURITY NUMBER WITH THIS FORM.  
Upload requirements
This is for the duration of the current license.
Upload requirements
Upload requirements
Upload requirements
Upload requirements
Adding Additional Controlled Substance Agent(s)?
Upload requirements
Mail Check Directly to:

New York State Department of Health
Bureau of Narcotic Enforcement
Riverview Center
150 Broadway, Menands, NY 12204
 

*Under provisions of section 3305.4 of PHL municipalities operating EMS agencies are exempt from the application fee.

Include*Check must include the CS license number on the memo line or mail a copy of Page 1 of the 3826 with the check


Upload requirements
Level of Care
Primary or Alternative Agent
Additional Agents
List only currently BEMS approved Controlled Substance agents
Does your Operation's Plan include Ketamine?
Are any providers currently certified at the Critical Care Level?
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If any of the following below have changed, please complete the forms below 

Upload requirements
Upload requirements
Include only employees/members who are authorized to administer controlled.
DO NOT INCLUDE EMS PROVIDER DATE OF BIRTH AND SOCIAL SECURITY NUMBER WITH THIS FORM.  
Upload requirements
This is for the duration of the current license.
Upload requirements
Upload requirements
Upload requirements
Adding Additional Controlled Substance Agent(s)?
Upload requirements
If any changes occur after your Controlled Substance License has been issued you must submit the changes here:
Upload proposed Controlled Substance Plan Cover Letter Summarizing the proposed changes (all changes must be approved by the Department prior to implementation)
 
Upload requirements
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Upload requirements
Are you removing any Controlled Substance Agent(s)?
Upload requirements
Adding Additional Controlled Substance Agent(s)?
Please add a DOH-3827 for each additional Controlled Substance Agent

Upload requirements
Upload requirements
Upload requirements
Upload requirements
Upload requirements