DEA Form 222 Request

Schedule-II pharmaceuticals cannot be sent to PharmaLink without a DEA FORM 222 accompanying the product during shipping. Please complete our on-line DEA Form 222 request or download a request form and fax it to the Compliance Department at (727) 669-8327. Should you have any questions or need help in any way, please contact the Compliance Department via e-mail at compliance@pharmalinkinc.com or call (800) 257-3527.

Please use the form below to provide us with your company information and Schedule II return information. You must use exact counts of all partial products.

Please read the instructions carefully before submitting the form.
Failure to do so may result in delays with processing your request.

INSTRUCTIONS

Completely fill out all fields on the DEA Form 222 Request form below.
A DEA 222 Request is ONLY for C-II items. Schedule 3-5 items do NOT require a DEA 222 request.
If navigating the form with a keyboard, please use the TAB key to move between textboxes. Pressing the ENTER key will submit the form; do NOT do so unless you are ready to submit your request.
Note that the form is limited to 10 line items; if you require more than 10 line items you will be required to submit a second request after the first.
For the Package Size field, enter the ORIGINAL quantity of the item.
Please note that if you have both full and partial quantities of an item, you must enter these as separate value. DO NOT COMBINE THE VALUES.
For the Package Size field, enter the ORIGINAL quantity of the item.
Before you submit the form, select File > Print from the toolbar menu to print a copy for your records.
Please allow 7-10 days for the receipt of your 222 form.

PLEASE LIST C-II ITEMS IN THE SPACES PROVIDED BELOW. THERE ARE 10 SPACES PROVIDED FOR YOUR PRODUCTS. IF YOU HAVE MORE ITEMS TO LIST, YOU MAY CONTINUE TO ENTER ADDITIONAL ITEMS AFTER CLICKING SUBMIT.

NOTE THAT YOU WILL NEED TO RE-ENTER YOUR FACILITY INFORMATION.

Facility Information

Facility Name:	Contact Person:
Street Address:	City:
State:	Zip Code:
Email Address:	Phone Number:
State License No:	DEA Number:
DEA Expiration Date:	Entry Date:

No. Packages	Exact Quantity	Package Size	Name of Item	NDC	Dosage Form/Strength (i.e. TABS/ 7.5-325 mg)
1	25	100	EXAMPLE: Oramorph SR Tab	00054-4790-25	Tabs / 25mg
2	46	100	EXAMPLE: MS Contin Tab	0034-514-10	Tabs / 15 mg

No. Packages	Exact Quantity	Package Size	Name of Item	NDC	Dosage Form/Strength (i.e. TABS/ 7.5-325 mg)










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	Before you submit the form, select File > Print from the toolbar menu to print a copy for your records.