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Policies,Administrative,UW Health Administrative,Administration

Prescriber DEA Registration Numbers (1.63)

Prescriber DEA Registration Numbers (1.63) - Policies, Administrative, UW Health Administrative, Administration

1.63


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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority as integrated effective July 1, 2015, including the legacy operations and staff of
University of Wisconsin Hospital and Clinics and University of Wisconsin Medical Foundation.
Policy Title: Prescriber DEA Registration Numbers
Policy Number: 1.63
Effective Date: April 1, 2017
Chapter: Administration
Version: Original
I. PURPOSE
To specify the options and steps for Graduate Medical Education Residents to obtain and utilize a DEA
number for take-home controlled substance prescribing. The scope of this policy includes only those
residents and fellows in ACGME accredited programs that are sponsored by the University of Wisconsin
Hospitals and Clinics (UW Health). This does not include:
1. residents sponsored by the University of Wisconsin School of Medicine and Public Health
(UWSMPH), such as Family Medicine;
2. visiting residents; and
3. residents in unaccredited programs (not accredited by the ACGME).

II. DEFINITIONS
“Institution DEA Registration Number” is the hospital DEA registration number. This would include
wholly owned UW Health entities with a DEA registration number (University Hospital, American
Family Children’s Hospital and The American Center; this would not include the UW Rehabilitation
Hospital). An institutional DEA registration number, when combined with a unique prescriber number
assigned to a specific prescriber, authorizes that prescriber to administer, dispense, and prescribe
controlled substances.

“Personal DEA Registration Number” is a unique number issued by the Drug Enforcement
Administration (“DEA”) to a licensed, eligible prescriber who applies for the right to dispense,
administer, or prescribe controlled substances.

“Unique Prescriber Number (UPN)” is the Graduate Medical Education Department assigned number that
links a prescriber to a registry of names to be provided to law enforcement and other DEA registrants
when required. The UPN is a suffix to the Institution DEA Registration Number.

The term “resident” refers to residents and fellows in ACGME-accredited Graduate Medical Education
(GME) programs sponsored by the University of Wisconsin Hospitals and Clinics (UW Health).

III. POLICY ELEMENTS

A. All prescribers must use a valid DEA registration number on all controlled substance
prescriptions for discharged inpatients and patients treated in ambulatory clinics.


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B. Faculty prescribers, advanced practice providers, and unaccredited fellows must obtain a Personal
DEA registration number if prescribing take-home controlled substances.
C. Residents who do not have a Personal DEA Registration number may use the Institution DEA
Registration Number with an assigned UPN when prescribing take-home controlled substances.
Once the resident has obtained a Personal DEA Registration Number, he or she is required to use
that number, and may not use, the Institution DEA Registration Number and UPN for any reason.
If the resident is excused from the requirement to apply for a Personal DEA Registration Number,
the prescriber’s UPN will expire at the end of his or her UW Health training program.
D. Use of the Institution DEA Registration Number and UPN is limited to the prescriber’s activities
within the course of their employment at UW Health and excludes moonlighting activities.
E. The Institution DEA Registration Number can be used only by agents or employees of the
hospital where controlled substance prescribing is in the usual course of their professional
practice as authorized by the state of Wisconsin.
F. Graduate Medical Education maintains a list of UPNs and prescribers, and can make it available
to other DEA registrants and law enforcement agencies when required.

IV. PROCEDURE

A. Prior to a resident’s start date, the GME office will issue a UPN to be used as a suffix to the
Institution DEA Registration Number on all take-home controlled substance prescriptions.
B. The GME office will submit UPNs to Information Services for entry into Health Link (SER).
C. Graduate Medical Education will maintain an updated registry of UPNs and prescriber names to
be maintained in the residency management system.
D. All take-home controlled substance prescriptions written by residents require both the Institution
DEA Registration Number and the assigned UPN suffix, including hand-written prescriptions.
E. When required to obtain a personal DEA registration number, GME will notify residents of the
requirement. A personal DEA number can be obtained after receiving a full Wisconsin medical
license, via the DEA website at http:www.deadiversion.usdoj.gov/index.html.
F. When a resident receives a personal DEA registration number or ends employment with UW
Health, the GME Office will notify Information Services with the update. The UPN will not be
utilized under either of these conditions.

V. COORDINATION

Sr. Management Sponsor: SVP, Chief Clinical Officer
Author: Pharmacy Coordinator, Medication Safety and Regulatory Compliance
Reviewer(s): Director, Graduate Medical Education; Legal Services

Approval Committee(s): Graduate Medical Education Committee; UW Health Administrative
Policy and Procedure Committee

SIGNED BY

Elizabeth Bolt
UW Health Chief Administrative Officer

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