Health Facility Petition Logging
Requestor
Facility Name
*
Facility Street
*
Facility City
*
Facility State
*
Facility ZIP Code
*
Requestor Title
Requestor First Name
*
Requestor Last Name
*
Requestor Email Address
*
Prescriber Review
Prescriber First Name
Prescriber Last Name
Prescriber DEA Number
Prescriber Comment
Phamacy Review
Facility DEA Number
Comment
Pharmacist Review
Employee First Name
Employee Last Name
Street Addres
City
State
Zip Code
Social Security Number
Comment
 
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CHFS Application Name