PMP Certification of No Dispensing of Controlled Substances Form

Alabama Prescription Drug Monitoring Program
Account Registration Form
MEDICAID
Please provide the information requested below.
Last Name*:
First Name:*
Last Four Digits of SSN:*
Date of Birth:*
Middle Initial:
Facility Name:*
Street Address*
City*
Phone*
State*
Zip Code*
Fax
Email*
Security Question*:
Security Answer*:
* indicates a required field
Privacy Statement
Statutory Authority: The Alabama Department of Public Health was given authority under Code of Ala. 1975§
20-2-210 et seq. to establish, create, and maintain a controlled substances prescription database program.
This program is to promote the public health and welfare by detecting diversion, abuse, and misuse of
prescription medications classified as controlled substances under the Alabama Uniform Controlled
Substances Act.
Access to Information:
Medicaid
In accordance with Code of Ala., § 20-2-214, access shall be permitted to information in the controlled
substances database to, “authorized representatives of the Alabama Medicaid Agency; provided, however,
that access shall be limited to inquiries concerning possible misuse or abuse of controlled substances by
Medicaid recipients.”
By signing this document, I hereby agree to follow the security and password policies of the Alabama
Prescription Drug Monitoring Program (PDMP). I agree to not disclose nor misrepresent any data or protected
health information to any unauthorized person or party. I agree that I will not share my account information,
login name, or password with anyone, even if they are authorized users of the program. Any person who
falsely swears, by signing this form, shall be guilty of a Class A misdemeanor (Code of Ala. § 13A-10-102).
Unlawful Disclosure:
Any person who intentionally makes an unauthorized disclosure of information contained in the controlled
substances prescription database shall be guilty of a Class A misdemeanor. Any person or entity who
intentionally obtains unauthorized access to or who alters or destroys information contained in the controlled
substances database shall be guilty of a Class C felony. (Code of Ala. 1975, § 20-2-216)
I understand that inappropriate access or disclosure of this information is a violation of Alabama law and may
result in disciplinary action by my licensing board and/or revocation of database access privileges.
Alabama Prescription Drug Monitoring Program
Account Registration Form
MEDICAID
Account Agreement:
By signing this agreement I hereby agree to follow the security and password policies of the Prescription Drug
Monitoring Program. I agree to not disclose nor misrepresent any data or protected health information to any
unauthorized person or party. I agree that I will not share my account information, login name, or password
with anyone, even if they are authorized users of the program. Any person who falsely swears, by signing this
form, shall be guilty of a Class A misdemeanor (Code of Ala. 1975, § 13A-10-102).
I certify under penalty of perjury under the laws of the State of Alabama that the foregoing is true and
correct.