Download Report

Nembutal Sodium Solution CII
®
(pentobarbital sodium injection, USP)
Order by Phone — Mail DEA 222 Form
APPROVED HEALTHCARE FACILITIES INSTRUCTIONS:
1 Complete DEA 222 Form (as indicated in the sample form below)
Nembutal® Sodium Solution CII (pentobarbital sodium injection, USP) must be the ONLY product on the DEA 222 form and
purchase order.
See Reverse of PURCHASER’S
No order form may be issued for Schedule I and II substances unless a
completed application form has been received, (21 CRF 1305.04).
STREET ADDRESS
Copy for Instructions
TO: (Name of Supplier)
CITY and STATE
Akorn, Inc.
Fill in number
of packages,
size, and name
of Nembutal
items you
wish to order.
L
I
N
No. of
E Packages
No.
1
2
5
3
3
4
5
6
7
8
9
Note last line
completed.
10
Size of
Package
Today’s Date
TO BE FILLED IN BY PURCHASER
National Drug Code
E
L
P
M
SA
20 mL x 1 Nembutal 50 mg/mL 20 mL
50 mL x 1 Nembutal 50 mg/mL 50 mL
(MUST BE 10 OR LESS)
TO BE FILLED IN BY SUPPLIER
SUPPLIERS DEA REGISTRATION No.
Name of Item
LAST LINE
COMPLETED
2
150 S. Wyckles Road
DATE
Decatur, IL 62522
OMB APPROVAL
No. 1117-0010
SIGNATURE OF PURCHASER
OR ATTORNEY OR AGENT
Packages
Shipped
Date
Shipped
To be completed
by Akorn Pharmaceuticals
Authorized Signature
Use the name
and address
shown here to
complete the
top section.
Insert today’s
date.
Obtain
authorized
signature.
2 Collect Purchasing & Licensing Information
Each time you place a new order for Nembutal® Sodium Solution CII (pentobarbital sodium injection, USP), you must provide
the following documents:
• Copy of your current DEA License
• Purchase order for Nembutal® products only
• Completed DEA 222 form using the sample form above as a guide
®
Nembutal Sodium Solution CII (pentobarbital sodium injection, USP)
NDC
PRODUCT DESCRIPTION
SIZE
UNIT OF SALE
76478-501-20
50 mg/mL, Multi-dose Vial CII
20 mL
1
76478-501-50
50 mg/mL, Multi-dose Vial CII
50 mL
1
3 Finalize Your Order…
Contact Akorn by Phone!
Express Ship Your Documentation
Call (800) 932-5676 to let us know you
have a Nembutal® Sodium Solution CII
(pentobarbital sodium injection, USP) order
on the way.
Retain tracking information for your records.
Ship completed documents to:
Akorn, Inc.
150 S. Wyckles Road
Decatur, IL 62522
Attn: Nembutal Processing Department
1925 West Field Court, Suite 300 • Lake Forest, IL 60045 • 800-932-5676 • Fax 800-943-3694 • www.akorn.com
P326 Rev. 11/13
Nembutal Sodium Solution CII
®
(pentobarbital sodium injection, USP)
Order Online — Electronic DEA e222 Form
1 Prepare to use AkornDirect.com CSOS
Before using the system, you will need the following:
• CSOS Certificate* — To apply for a CSOS Certificate, visit the DEA E-commerce website
(http://www.deaecom.gov/applycert.html) and follow the on-screen instructions
• Akorn Direct Customer Account — An account can be obtained or verified by contacting
Akorn’s Customer Service at 800-932-5676 today
2 Submit your Controlled Substance Online Order
Once you meet the requirements above, you are ready to place your order online with the AkornDirect.com CSOS ordering system.
Login to start your order
Add your controlled substance
product to your shopping cart
PLEASE NOTE: When ordering Nembutal® Sodium Solution (pentobarbital sodium injection, USP), Nembutal® must be
the ONLY product in your cart. DO NOT combine other products with this order.
3 Follow the Step-by-Step Online Instructions
The AkornDirect.com CSOS system will step you through the following screens to complete your order:
• Checkout Process—Enter contact information, special delivery instructions, and a unique 6-digit identification number
• Confirmation Process—Review your DEA e222 Form and upload your DEA CSOS electronic certificate
• Approval Process—Wait for DEA e222 verification
For detailed ordering instructions, system requirements and to learn
how to use Akorn CSOS, visit akorn.com/csos-setup
* A CSOS Certificate is a digital identity issued by the DEA’s CSOS Certification Authority that allows for electronic ordering of controlled substances.
1925 West Field Court, Suite 300 • Lake Forest, IL 60045 • 800-932-5676 • Fax 800-943-3694 • www.akorn.com