Electronic Prescribing Waiver

Name as it appears on Podiatry License*

Doctor of Podiatric Medicine license number*

DEA Number*

Email Address*

Phone Number*

You must attach the completed and signed Doctor of Podiatric Medicine Electronic Prescribing Waiver form along with documentation supporting one of the following conditions:

Demonstrated Economic Hardship
Technological Limitations
Exceptional Circumstances

Forms received without supporting documentation will not be accepted.

Attachments (BMP, DOC, DOCX, GIF, JPEG, JPG, PDF, PNG, TIFF, XLS, XLSX)*

Drop files here, or browse to attach files

Confirmation Required

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**Note: Max total upload size is 35MB. If your total attachment size is larger than 35MB, your email will not be received. You can submit additional files
by filling out this form again with the extra attachments.

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