The NY-DOH Form 4004, or Controlled Substances Usage Verification Form, is completed prior to restocking from a hospital/pharmacy or when turning in controlled substances to the hospital/pharmacy for destruction. A form must be completed for each named controlled substance to includes drug amounts administered, wasted, and/or destroyed.
Starting a New Form 4004
Navigate to Forms > NY 4004
Add Form 4004 & Select Controlled Substance
Override Date Range (If different than date of last replenishment)
- If using the date of last replenishment, click on "Skip"
Select Hospital/Pharmacy & Review Transactions
Choose the hospital or pharmacy that you are submitting to from the drop down. If you do not see the name of the hospital/pharmacy on this list, they will need to be added as a new supplier first.
Schedule2 will automatically populate the inventory events from the selected date range into the list of transactions. Review these transactions to ensure everything is correct, including the beginning and ending inventory balance.
Manual Transaction Entries (If needed)
To manually add a transaction to the list, select the green + icon.
Enter the required fields, then click on "Add".
Add Verification Signature & Print Form
Once all transactions are reviewed, the CS Agent will enter their PIN to add a verification signature, completing the form.
After completion, you can now select "Print View" and print the form for your records.
- Retain for at least 5 years, as per 10 NYCRR §80.135 and DEA guidelines.