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 2019-2020 and form must be updated in 2021.  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.

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* Pharmacy/Veterinarian/Veterinarian Clinic Name

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* Pharmacist/Veterinarian in Charge (PIC)

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* Pharmacy/Veterinarian/Veterinarian Clinic Address 1

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* Pharmacy/Veterinarian/Veterinarian Clinic Address 2

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* Pharmacy/Veterinarian/Veterinarian Clinic City

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* Pharmacy/Veterinarian/Veterinarian Clinic State

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* Pharmacy/Veterinarian/Veterinarian Clinic Zip Code

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* Pharmacy/Veterinarian/Veterinarian Clinic Phone Number

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* Pharmacy/Veterinarian/Veterinarian Clinic Point of Contact Email Address

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* Pharmacy or Veterinarian License/Permit Number

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* Pharmacy or Veterinarian DEA Registration Number

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* Pharmacy NPI number (Veterinarian n/a)

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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:

Please contact NeHII Support with questions regarding exemptions at PDMP@nehii.org or phone:  1-402-506-9900.
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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