Version 16.3
Office-Based Treatment Prescribing Only
Application for Registration (Form DHHS 224-E)
NC Department of Health and Human Services
Division of Mental Health, Developmental Disabilities, and Substance Abuse Services – Drug Control Unit
3008 Mail Center Service Center
Raleigh, North Carolina 27699-3008
(919) 733-1765
Application Instructions – PLEASE READ THESE INSTRUCTIONS CAREFULLY
This application will be used by the North Carolina Department of Health and Human Services’ Drug Control Unit to initiate a registration for the
applicant under the North Carolina Controlled Substances Act of 1971 as well as assist in determining whether or not the applicant is in compliance
with State and Federal laws pertaining to controlled substances. Therefore, please fill out this application in its entirety. Do not leave any fields blank,
rather indicate that a field is not applicable by typing “N/A” in the space provided. Failure to complete the entire form will result in the application
being returned to the applicant along with a request for additional information. To submit this Application for Registration, e-mail both the completed
electronic PDF and a signed PDF copy to nccsareg@dhhs.nc.gov along with a signed PDF copy of an Applicant Disclosure of Loss, Diversion, or
Destruction of Controlled Substances (Addendum to Forms DHHS 224 and 225).
Attestation
By signing below, you attest that the information provided on this form is true, accurate, and complete to the best of your knowledge. All responses
are subject to verification by the North Carolina Department of Health and Human Services’ Drug Control Unit. Furthermore, you acknowledge that
you have read and understand NC GS 90-101(a1):
“(a1) Any physician who prescribes or dispenses Buprenorphine for the treatment of opiate dependence shall annually register with the Department, in
accordance with rules adopted by the Commission. In the application for registration under this subsection, the applicant shall document plans to ensure that
patients are directly engaged or referred to a qualified provider to receive counseling and case management, as appropriate, and shall acknowledge the
application of federal confidentiality regulations to patient information. Applicant plans for referral to appropriate services shall be a written document and
may include either an executed memorandum of agreement, contractual arrangement, or linkage agreement with qualified providers. The Department shall
provide assistance upon request to physicians registered under this subsection to identify and establish linkages with qualified providers of counseling and case
management. The Department shall provide the North Carolina Medical Board with any evidence of noncompliance with this subsection by a qualified
physician prior to taking action to rescind the physician’s registration to prescribe or dispense Buprenorphine for the treatment of opiate dependency.”
Section A - Applicant Information
Facility’s State, City, Zip
Section B - Registration Classification
B1. Check all applicable drug schedules in which you are applying for:
☐ Schedule III (Narcotic)
B2. Are you currently authorized to manufacture, distribute, dispense, prescribe, conduct research, or
otherwise handle controlled substances in the schedules for which you are applying under the laws of
North Carolina or the Federal Government?
B3. Has the applicant been convicted of a felony under State or Federal law relating to the manufacture,
possession, distribution, or dispensing of controlled substances?
B4. Has any previous registration held by the applicant, corporation, firm, partner, or officer of applicant
under Federal CSA or NCCSA been surrendered, revoked, suspended, denied, or is it pending such action?
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