:: Initial Applications ::

Waiver of Fee -- Determination of Eligibility

Income-based Fee Waiver --An applicant for an initial license or registration is eligible for a waiver of the initial fee(s) if the applicant’s adjusted gross household income does not exceed 200% of the Federal Poverty Level and the applicant is applying for this specific license/registration category for the first time.

To determine eligibility, you must first identify the number of individuals in your household. Once this is determined, reference the Federal Poverty Level and identify your adjusted gross household income that matches the number of individuals in your household. If your adjusted gross household income, as reported on your most recent federal tax return, is less than the identified value, you are eligible for the one-time fee waiver.

If you determine that you are eligible for the one-time fee waiver, you will be provided an opportunity to request the waiver at the end of this application. You will also be required to upload a copy of your household Federal Tax Return for the preceding year.

If you are married and filed separately, you will need to submit the Federal Tax Return for both your spouse and yourself.
If you were claimed as a dependent on another person’s tax return, you will need to submit the Federal Tax Return for the tax filer who claimed you as a dependent.

Military Veteran Fee Waiver – Military veteran applicants are eligible for waiver of the initial application fee and one renewal fee if the applicant was honorably or generally discharged from federal active duty or National Guard duty within five (5) years prior to application submission. Applicants seeking waiver of the initial application fee or renewal fee must submit a copy of their Certificate of Release or Discharge from Active Duty (DD Form 214) or Verification of Military Experience and Training (VMET-DD Form 2586).

Please be sure you have the required documents ready before proceeding with this application. If your documents are not available for upload when the waiver opportunity is presented, you may need to redo this entire application to request a fee waiver.

Controlled Substance Act Registration for Individual Practitioners or Researchers

You are applying for an Iowa Controlled Substance Act Registration for an individual practitioner or researcher. “Individual Practitioner” means: a physician or surgeon (M.D.), osteopathic physician or surgeon (D.O.), dentist (D.D.S. or D.M.D.), doctor of veterinary medicine (D.V.M.), podiatric physician (D.P.M.), optometrist (O.D.), physician assistant (P.A.), advanced registered nurse practitioner (A.R.N.P.),pharmacist (R.Ph. or Pharm.D.) or prescribing psychologist. Registration is required for individual practitioners located in Iowa who are administering, dispensing, or prescribing controlled substances and individual practitioners located outside of Iowa who are dispensing or prescribing controlled substances to patients located in Iowa. Registration is also required for individual researchers who are utilizing controlled substances in their research.

This application should only be used by an individual who has never held an Iowa CSA-Individual (CSA-I) registration, who is reactivating a CSA-I registration that expired more than four months prior to the current date, or who has a current/active CSA-I registration and is applying for another CSA-I registration at a new location. If you maintain a stock supply of controlled substances at multiple locations, a separate CSA-I registration is required for each location where controlled substances are stocked by the registrant.

If you are not sure if you ever held an Iowa CSA-I registration or you need to check the status of your existing registration, you can search by your name OR your CSA-I registration number HERE. Application fees are nonrefundable regardless of whether a registration is issued or not.

This application is not to be used to renew a current/active CSA-I registration. Online renewals of CSA-I registrations can be submitted HERE beginning 60 days prior to expiration and up to four months following expiration of the registration.

All application fees are nonrefundable. Once this application is submitted and the fee is paid, the withdrawal of an application or discovery of a duplicate application or registration does not merit return or refund of the application fee. Do not submit this online application if you have previously completed an initial online application or mailed a hard-copy application and payment.

Prescription Monitoring Program (PMP) Registration Required

Registration with Iowa’s Prescription Monitoring Program (PMP) is required for all individual prescribers except veterinarians or researchers. Once you receive your Iowa CSA-I registration number and your Iowa DEA registration number, you can register to use the Iowa PMP at iowa.pmpaware.net. Once your CSA registration is approved, it will be issued with a status of “Pending PMP.” With this status, you may then apply for or transfer your federal DEA registration (if necessary). Once you obtain your DEA registration, you must register with the Iowa PMP. Once registered with the PMP, your Controlled Substance Act Registration status will be switched to “Current/Active” and you may begin administering, dispensing, or prescribing controlled substances. Please refer to your professional licensing authority for requirements pertaining to mandated use of the Prescription Monitoring Program.

This requirement does NOT apply to licensed veterinarians and researchers.

Iowa Regulations

481 Iowa Administrative Code Chapter 553 governs the administrative procedures pertaining to the procurement, storage and handling, prescribing, dispensing and record keeping of controlled substances in the state of Iowa.

Have you reviewed and do you understand the Iowa regulations pertaining to administrative procedures pertaining to controlled substances?

Yes

481 Iowa Administrative Code Chapter 556 governs Iowa’s Prescription Monitoring Program (PMP). For mandatory use requirements, please refer to your professional licensing board’s rules.

Have you reviewed and do you understand the Iowa regulations pertaining to the Prescription Monitoring Program?

Yes

Military or Veteran Status

1.Are you active duty military?

Yes

2.Are you a Federal or National Guard Veteran

Yes

3.Are you the spouse of an active duty military member or veteran?

Yes

Required Documents

The following documents may be required to be uploaded with your application:

1. Any disciplinary actions taken against your professional license in any jurisdiction

2. Any final disciplinary orders in any jurisdiction

3. Last year’s Federal Income Tax Return

4. Certificate of Release or Discharge from Active Duty (DD Form 214)

5. Verification of Military Experience and Training (VMET—DD Form 2586)

6.Any documentation of criminal convictions and court records related to prescription drugs, controlled substances, healthcare, or the practice of your profession in any jurisdiction

7. Approved research protocols

Any Prior Iowa Board of Pharmacy Licensure

Have you ever been licensed or registered with the Iowa Board of Pharmacy in any capacity?

Yes

Full Name

Street Address

C S Z

License #

Registration Sub-type

Please select your controlled substance act registration sub-type

Current Research Protocol

Registrant Information

Provide Full Legal Name

Last Name

First Name

Middle Name

Gender

Social Security #

Date of Birth

Previous/Other Name(s) Used

Iowa Practice or Business Address

Business Name

Address 1

Address 2

Address 3

Country

Zip

City

State

County

Mailing Address

Check if mailing address is the same as physical address

Address 1

Address 2

Address 3

Country

Zip

City

State

County

Contact Information

Phone Type

Primary Phone #

Accept Text Message

Yes

Alternate Phone Type

Alternate Phone # for Facility

Accept text message

Yes

E-mail

Fax #

Licensure Information

Attention: The Professional License # and Expiration Date must exactly match your Iowa professional license information. For example, DDS-xxxxx, DO-xxxxx, MD-xxxxx, etc.

Type of practitioner

Iowa Professional License #

Professional License Expiration Date

Federal DEA#

Federal DEA Expiration Date

Criminal History (New applicants must provide a complete history.)

Since your last application, have you been convicted of a criminal offense, other than a minor traffic offense, in any jurisdiction? Conviction means a finding, plea, or verdict of guilt made or returned in a criminal proceeding, even if the adjudication of guilt is deferred, withheld, or not entered. Conviction includes Alford pleas and pleas of nolo contendere. If not previously provided to this Board, you must submit the complaint and judgement of conviction for each offense and a personal statement regarding whether each conviction directly relates to controlled substances, or the practice of your profession. Your application will not be considered complete until all of this information is received by the Board. Include a separate sheet of paper providing a signed and dated explanation of each conviction and attach court records of the conviction(s) if not previously provided to this Board.

Yes

Disciplinary Actions (New applicants must disclose all disciplinary actions described below.)

Since your last application, have you had a professional license or registration in any jurisdiction revoked, suspended, or otherwise disciplined?

Yes

Surrenders in lieu of Disciplinary Actions (New applicants must disclose all disciplinary actions described below.)

Since your last application, have you surrendered (in lieu of disciplinary action) or had a CSA or DEA registration in any jurisdiction, revoked, suspended, disciplined, or denied?

Yes

Pending Investigations

Since your last application have you had any charges, or do you know of any investigations, complaints, or charges pending before any licensing authority?

Yes

Preview

Please review your application and return, using the Previous button, to any page(s) that needs to be changed or corrected.
Once you click the Next button on this page you will not be able to make any changes to your application.

Confirm and Submit

I hereby swear or affirm under penalty of perjury that the information provided in this application is true and correct. I understand that failure to provide complete and truthful information may constitute grounds for denial, revocation, or other disciplinary sanctions against my registration. I understand that this application is a public record in accordance with Iowa Code chapter 22 and that any information provided on this application may be disclosed pursuant to 481 IAC Chapter 5.

Signature of Applicant:

Date :

Printed Name :

CSA-I Initial and Reactivation Application