Controlled Substance Submissions

Welcome to the New York State Department of Health Division of State EMS 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

All forms submitted must be on the most recent form version. Application's utilizing an old version of any form will be rejected.

All current forms can be found here: https://apps.health.ny.gov/pubpal/builder/EMSForms

Submission Type

Initial Application (This includes Physical Address Changes)

Renewal Application

Interim Change

Semi- Annual Reports Submission

Loss of Controlled Substances Report Submission

NYS DOH EMS Region

County

Name of Service

Agency Code

Is your agency owned by a municipality?

Yes

Name of Contact Person

Full Name

Phone

Medical Director Information

Full Name

Phone

Level of Care

Copy of the $100.00 payment mailed to Bureau of Narcotic Enforcement

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.

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

Upload requirements

Current Narcotics License Number (3C-)

Select the storage and security to be used to safeguard the narcotics:

Safe

Cabinet

Cameras

Other…

Describe storage and security used along with make and model numbers, photos must be submitted below:

Storage and Security Photo(s) Upload

Upload requirements

DOH-3826 Application for ALS Agency to Engage in Controlled Substances Activity for Prehospital Care.

Upload requirements

Copy of Operating Certificate

Upload requirements

DOH-3827 Application to be a Controlled Substance Agent for an ALS Agency

Upload requirements

DOH-4362 Medical Director Verification

Upload requirements

DOH-2828 EMS Agency Personnel Roster

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

DOH-3848 Controlled Substance Report for Emergency Medical Services Agencies

This is for the duration of the current license.
Upload requirements

Copy of Current Controlled Substances License

Upload requirements

Current Controlled Substances Operations Plan

Upload requirements

Supplier Agreement

Upload requirements

Adding Additional Controlled Substance Agent(s)?

Yes

Additional CS Agent File Upload: DOH-3827

Upload requirements

Copy of the $100.00 payment mailed to Bureau of Narcotic Enforcement

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

List your agency's current BEMS Approved Controlled Substance Agents

List your agency's current BEMS Approved Controlled Substance Agents
First Name Last Name Level of Care Critical Care Paramedic Primary or Alternative Agent Primary Agent Alternative Agent Certification Number Expiration Date

Additional Agents

List only currently BEMS approved Controlled Substance agents

Does your Operation's Plan include Ketamine?

Yes

Are any providers currently certified at the Critical Care Level?

Yes

Current Narcotics License Number (3C-)

Copy of Current Controlled Substances License

Upload requirements

DOH-3826 Application for ALS Agency to Engage in Controlled Substances Activity for Prehospital Care.

Upload requirements

Storage and Security Photos

Upload requirements

Copy of Operating Certificate

Upload requirements

If any of the following below have changed, please complete the forms below

DOH-3827 Application to be a Controlled Substance Agent for an ALS Agency

Upload requirements

DOH-4362 Medical Director Verification

Upload requirements

DOH-2828 EMS Agency Personnel Roster

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

DOH-3848 Controlled Substance Report for Emergency Medical Services Agencies

This is for the duration of the current license.
Upload requirements

Current Controlled Substances Operations Plan

Upload requirements

Supplier Agreement

Upload requirements

Adding Additional Controlled Substance Agent(s)?

Yes

Additional CS Agent File Upload: DOH-3827

Upload requirements