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NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Emergency Medical Services Bureau of Narcotic Enforcement Controlled Substances Usage Verification Name Controlled Substance Submitted to (Hospital/Pharmacy)

How to fill out doh 4004 - health

How to Fill Out DOH 4004:

1. Begin by gathering all the necessary information and documents. This includes personal information such as your name, address, and contact details.
2. Next, carefully read through the instructions provided with the DOH 4004 form. Make sure you understand each section and what information is required.
3. Start by filling out the basic information section at the top of the form. This typically includes your full name, date of birth, and social security number.
4. Move on to the next sections, which may vary depending on the purpose of the form. These sections may require you to provide information about your current medical condition, any medications you are currently taking, or any previous medical history that may be relevant.
5. As you fill out each section, double-check your answers for accuracy. It's important to provide truthful and accurate information to ensure the form is completed correctly.
6. If you encounter any sections that are unclear or confusing, don't hesitate to reach out for clarification. You can contact the relevant authority or organization that provided you with the DOH 4004 form for assistance.
7. Once you have completed all the required sections, review the entire form again to ensure no mistakes or omissions were made. Correct any errors before submitting the form.
8. Finally, submit the completed DOH 4004 form according to the instructions provided. This may involve mailing it to a specific address or submitting it online through a secure portal.

Who Needs DOH 4004:

1. Individuals seeking medical assistance or services from a healthcare provider may be required to fill out DOH 4004. This includes patients visiting hospitals, clinics, or other healthcare facilities.
2. DOH 4004 may also be required for individuals applying for certain insurance policies or medical coverage.
3. Additionally, healthcare professionals or administrators may need to fill out DOH 4004 for organizational purposes, such as maintaining accurate and up-to-date patient records.

Overall, the DOH 4004 form is typically required by individuals seeking medical assistance or services, as well as healthcare providers for administrative purposes. It is important to carefully fill out the form with accurate information to ensure proper documentation and support in the healthcare process.

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