COMMONWEALTH OF VIRGINIA 9960 Mayland Drive, Suite 300 of Health Professions Richmond, VA 23233 Phone: (804) 367-4514 Prescription Monitoring Program Fax: (804) 527-4470 Software Vendor: Appriss pmp@dhp.virginia.gov Contact Information: Phone: 1-855-482-4767 Ticket Request: Prescription upload web site: ACCOUNT DEVELOPMENT FORM FOR REPORTING TO VIRGINIA’S PRESCRIPTION MONITORING PROGRAM Please provide the information requested below. (Print or Type) Facility Name: Manager Full Name: Days Facility Closed (if any) Sun Mon Tues Wed Thurs Fri Sat N/A Street Address: City: State: Zip Code: Work Area Code and Telephone Number: Email Address: Pharmacy, Dentist, Physician or DEA Number: NPI or Number (if available): Veterinarian License Number: Point Of Contact (POC) and VIC Full POC Address: POC Work Phone: Name: POC Signature: ________________________________ Date: _____________________________________ - VETERINARIANS ONLY Please select the appropriate checkbox. □ Reporting as an establishment (please attach waivers) Name(s)/License Number(s) of Veterinarian(s): □ Reporting as a sole practitioner. For Department Use Only Date Received: Approved Director or Designee Signature: Date Completed: Rejected
9960 Mayland Drive, Suite 300 Richmond, VA 23233 Phone: (804) 367-4514 Fax: (804) 527-4470 pmp@dhp.virginia.gov COMMONWEALTH OF VIRGINIA of Health Professions Prescription Monitoring Program Software Vendor: Appriss Contact Information: Phone: 1-855-482-4767 Ticket Request: Prescription upload web site: ACCOUNT DEVELOPMENT FORM FOR REPORTING TO VIRGINIA’S PRESCRIPTION MONITORING PROGRAM Please provide the information requested below. (Print or Type) Facility Name: Manager Full Name: Days Facility Closed (if any) Sun Mon Tues Wed Thurs Fri Sat N/A Street Address: City: State: Zip Code: Work Area Code and Telephone Number: Email Address: Pharmacy, Dentist, Physician or Veterinarian License Number: DEA Number: NPI or Number (if available): Point Of Contact (POC) and VIC Full Name: POC Address: POC Work Phone: POC Signature: ________________________________ - Date: _____________________________________ VETERINARIANS ONLY Please select the appropriate checkbox. □ Reporting as an establishment (please attach waivers) Name(s)/License Number(s) of Veterinarian(s): □ Reporting as a sole practitioner. For Department Use Only Date Received: Approved Rejected Director or Designee Signature: Date Completed:
DispenserRegistrationFormForReporting.docx