A watermark reading "Indiana Security Prescription" must be printed on the back of the paper; these words must appear at a 45 degree angle, horizontally in a step-and-repeated pattern in 5 lines, using 12-point Helvetica bold type style;
An opaque RX symbol must appear in the upper right-hand corner corner, 1/8 of an inch from the top and 5/16 of an inch from the right side. This symbol must be 3/4 of an inch and disappear if the prescription copy is lightened;
Six (6) quantity check-off boxes and the following quantities must be printed on the form and the appropriate box checked off: "1-24", "25-49", "50-74", "75-100", "101-150", and "151 and over";
No advertisements may appear on the front or back;
Logos may appear in the upper left one-inch square;
Only one prescription may be written per blank. The following statement must be printed on the bottom of the pad: "Prescription is void if more than one (1) prescription is written per blank.";
Refill options that can be circled must appear below any logos and above the signature lines on the left side of the prescription in the following order: "Refill NR 1 2 3 4 5 Void after _____"
Practitioner full name, address, DEA number, and state issued license number must be preprinted, stamped, or manually printed on the prescription;
All prescription blanks must be 4 1/4 inches high and 5 1/2 inches wide;
Two signature lines printed at the bottom of the form: under the blank line on the left side must be printed the words "Dispense as Written", under the blank line on the right side must be printed the words "May Substitute".
The name of any controlled substance may not be preprinted on any prescription forms at any time prior to the prescription being prepared and executed for presentation to the patient or the patient's agent. That includes, but is not limited to, typing prescriptions in anticipation of their need and/or using a rubber stamp or similar means to accomplish the same end. Commercially printed forms containing names of controlled substances are also prohibited.
All controlled substance prescriptions written by Indiana licensed practitioners [as defined by IC 16-42-19-5] must comply with DEA requirements as well as with 856 IAC 1-34 and IC 16-42-22-6 in order for their prescriptions to be accepted for filling in Indiana licensed pharmacies.
Indiana licensed practitioners must use controlled substance prescription blanks (security feature prescription paper) from an approved vendor:
Security Feature Prescription Paper
All controlled substance prescriptions written by licensed Indiana practitioners must contain the following security features:
A latent, repetitive "void" pattern in reflex blue must appear across the entire face of the document when the prescription is photocopied;
Template of Indiana Security Features for Prescriptions
If you have any questions, please email the Indiana Board of Pharmacy at pla4@pla.IN.gov.