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1. Fill out the Customer Name, DEA Number, Pharmacy Contact, and Phone Number at the top portion of this form.



2. Please use a seperate certificate of transfer form for Schedule II drugs.



3. Please list information in the appropriate column:


Column 1: Enter the DEA classification of the item.
Column 2: Enter the name of the drug preparation.
Column 3: Enter the number of containers. A container is defined as a bottle, box, package, punch card, etc. You may wish to consider the box which all items are shipped in to be the container, ie. 1.
Column 4: Enter the contents or number of units per container (e.g. 1 gram, 2 ounces, 2 tablets, etc.). The number of contents may be considered to be the total number of tabs, caps, amps, vials, ml's, etc.
Column 5: Controlled substance content. This would be the strength of each tab, cap, amp, vial, etc. In the case of a syrup, or other liquid this would be the strength per ml.
Column 6: Enter the NDC number if it is a Schedule 2 & 3N. NDC isn't required for 3 through 5.
Column 7: Enter Manufacturers name if schedule 2. Not required for 3 through 5.


4. All items entered on each line must be identical in terms of content, package size, strength NDC #.



5. Upon completion of form, please type your name and date in the completed by section. Print off a copy for your records. Fax info to PCC at 615-373-7727.



6. You may ship all items in one container, but please package all classifications separately within the same shipping container.


If you have schedule 2's, we will transcribe from your certificate of transfer form to a 222 form. When you receive the 222 form, fill out the supplier portion of the form and forward the green copy to your local DEA office. Mail us your box of controls to:


Pharmaceutical Credit Corporation


130 Seaboard Lane, Suite A-6


Franklin, TN 37067


800-487-4308




7. A copy will be returned to you as your proof of receipt. This will also serve as a receipt of destruction.