For data uploaders/pharmacy users, this form is a voluntary option to provide information as it relates to meeting one of the identified exemptions according to Neb. Rev. Stat. § 71-2454(4) and Neb. Rev. Stat. § 71-2454(7)(b).  The information collected in this forms is specific to the listed exemptions as they apply in 2018 and form must be updated in 2019.  This is not a legally binding form.  The completion of this form does not guarantee your exemption from reporting to the Nebraska PDMP system.  All submitted forms will be cross referenced with the current licenses according to the Nebraska Department of Health and Human Services, Division of Public Health, Licensure Unit.

Pharmacy/Veterinarian/Veterinarian Clinic Name

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Pharmacy/Veterinarian/Veterinarian Clinic Name

Pharmacist/Veterinarian in Charge (PIC)

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Pharmacist/Veterinarian in Charge (PIC)

Pharmacy/Veterinarian/Veterinarian Clinic Address 1

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Pharmacy/Veterinarian/Veterinarian Clinic Address 1

Pharmacy/Veterinarian/Veterinarian Clinic Address 2

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Pharmacy/Veterinarian/Veterinarian Clinic Address 2

Pharmacy/Veterinarian/Veterinarian Clinic City

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Pharmacy/Veterinarian/Veterinarian Clinic City

Pharmacy/Veterinarian/Veterinarian Clinic State

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Pharmacy/Veterinarian/Veterinarian Clinic State

Pharmacy/Veterinarian/Veterinarian Clinic Zip Code

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Pharmacy/Veterinarian/Veterinarian Clinic Zip Code

Pharmacy/Veterinarian/Veterinarian Clinic Phone Number

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Pharmacy/Veterinarian/Veterinarian Clinic Phone Number

Pharmacy/Veterinarian/Veterinarian Clinic Point of Contact Email Address

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Pharmacy/Veterinarian/Veterinarian Clinic Point of Contact Email Address

Pharmacy or Veterinarian License/Permit Number

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Pharmacy or Veterinarian License/Permit Number

Pharmacy or Veterinarian DEA Registration Number

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Pharmacy or Veterinarian DEA Registration Number

Pharmacy NPI number (Veterinarian n/a)

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Pharmacy NPI number (Veterinarian n/a)

Exemptions:  (select one option below)
Dispenser is exempt from submitting per Neb. Rev. Stat. §§71-2454(7)(b) and 71-2454(4).
Dispenser means a person authorized in the jurisdiction in which he or she is practicing to deliver a prescription to the ultimate user by or pursuant to the lawful order of a prescriber but does not include:

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Exemptions:  (select one option below)
Dispenser is exempt from submitting per Neb. Rev. Stat. §§71-2454(7)(b) and 71-2454(4).
Dispenser means a person authorized in the jurisdiction in which he or she is practicing to deliver a prescription to the ultimate user by or pursuant to the lawful order of a prescriber but does not include:

If applicable:
Dispenser does not dispense ANY PRESCRIPTION DRUGS in Nebraska or to a Nebraska address and would like to voluntarily provide information to identify as an entity that does not have any data to submit to the PDMP to comply with Neb. Rev. Stat. § 71-2454 for 2018.

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If applicable:
Dispenser does not dispense ANY PRESCRIPTION DRUGS in Nebraska or to a Nebraska address and would like to voluntarily provide information to identify as an entity that does not have any data to submit to the PDMP to comply with Neb. Rev. Stat. § 71-2454 for 2018.

Please contact NeHII Support with questions regarding exemptions at PDMP@nehii.org, phone:  1-866-978-1799,
or fax:  1-866-550-6007

You will be receiving an email from Felicia.quintana-zinn@nebraska.gov acknowledging receipt and review of your Exemption Form.

This project is supported by Cooperative Agreement Number 1U17CE002736-01, funded by the Centers for Disease Control and Prevention. 

Please click the SUBMIT below to complete your form.

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