Power of Attorney to Sign an Official Order Form

Power of Attorney to Sign an Official Order Form
Any registrant (pharmacy) may authorize one or more individuals, whether or not they are located at the registered location, to obtain and execute Official Order Forms by granting a
power of attorney to each such individual. The power of attorney must be signed by the same person who signed the most recent application for registration or renewal registration,
as well as the individual being authorized to obtain and execute Official Order Forms. The power of attorney may be revoked at any time by the person who signed the power of
attorney. It is necessary to grant a new power of attorney when the pharmacy completes a renewal registration, only if the renewal application is signed by a different person. The
power of attorney should be filed with executed Official Order Forms as a readily retrievable record. The power of attorney is not submitted to DEA.
POWER OF ATTORNEY FOR DEA ORDER FORMS
__________________________________________________________________________________________________________________________ (Name of registrant)
__________________________________________________________________________________________________________________________ (Address of registrant)
__________________________________________________________________________________________________________________________ (DEA registration number)
I, Thomas G. Ronay, M.D., FACEP, the undersigned, who is authorized to sign the current application for registration of the above named registrant under the Controlled
Substances Act or Controlled Substances Import and Export Act, have made, constituted, and appointed, and by these present, do make, constitute, and appoint
_________________________________________________(name of attorney-in-fact), my true and lawful attorney for me in my name, place, and stead, to execute applications for
books of official order forms and to sign such order forms in requisition for Schedule I and II controlled substances, in accordance with Section 308 of the Controlled Substances Act
(21 U.S.C. 828) and part 1305 of Title 21 of the Code of Federal Regulations. I hereby ratify and confirm all that said attorney shall lawfully do or cause to be done by virtue hereof.
Signature of Thomas G. Ronay, M.D., FACEP
I, _________________________________________ (name of attorney-in-fact), hereby affirm that I am the person named herein as attorney-in-fact and that I agree to comply with
the Controlled Substance Policy. The signature affixed hereto is my signature.
Signature of attorney-in-fact
Witnesses:
1.
________________________________________________
Signature
____________________________________________________________
Printed Name
2.
_________________________________________________
Signature
___________________________________________________________
Printed Name
Signed and dated on the ______ day of ________________in the year_________ at _________________________________________________________.
NOTICE OF REVOCATION OF POWER OF ATTORNEY
The foregoing power of attorney is hereby revoked by the undersigned, who is authorized to sign the current application for registration of the above-named registrant under the
Controlled Substances Act or the Controlled Substances Import and Export Act. Written notice of this revocation has been given to the attorney-in-fact
_____________________________________________ this same day.
Signature of Thomas G. Ronay, M.D., FACEP
I ____________________________________________ am no longer involved and no longer have access to the controlled substances.
Signature
Witnesses:
1.
_________________________________________________
Signature
___________________________________________________________
Printed Name
2.
_________________________________________________
Signature
___________________________________________________________
Printed Name
Signed and dated on the ______ day of _______________, in the year_________ at _________________________________________________________
Source:http://www.deadiversion.usdoj.gov/pubs/manuals/pharm2/pharm_content.htm#p9d
K:\PublicData\COMPLIANCE\Narcotics\Power of Attorney to Sign an Official Order Form.docx
01/03/11