Pdf application for non resident pharmacy permit

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PDF Application for non-PIV Certificate

KENTUCKY BOARD OF PHARMACY
State Office Building Annex, Suite 300
125 Holmes Street
Frankfort KY 40601
Phone (502) 564-7910
Fax (502) 696-3806
e-mail: pharmacy.board@

Application For Non-Resident Pharmacy Permit
Please print legibly. Make check or money order payable to `Kentucky State Treasurer'. Mail completed application to the above address. All
applicable entries must be completed. Please use the checklist of required documentation at the end of this application. Incomplete
applications will be returned. Each permit expires June 30th following the date of issuance.
1. Name of Pharmacy ___________________________________________________________________________________
Physical Address of Pharmacy _________________________________________________________________________
(Street and Number)
City ____________________________________________________State _____________________Zip _______________
Phone Number ___________________Toll Free Number___________________Fax Number _______________________
Website Address__________________________________Email Address ______________________________________
Mailing Address of Pharmacy __________________________________________________________________________
(Street and Number)
City _____________________________________________________ State ___________________ Zip ______________
Check and complete one of the following and attach proper fee:
New Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100.00
Proposed date of Opening _____________________________________________
(Filed with Board 30 days in advance of Opening)
Change of Ownership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $75.00
Date of Proposed Acquisition _________________________________________
Name of Previous Owner(s) _________________________________________
(REQUIRED DOCUMENT: Confirmation statement of previous owner OR legal documentation of ownership change)
Change of Address/Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $75.00
Date of Proposed Relocation __________________________________________
Previous Address _____________________________________________________
Name Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NO CHARGE
Previous Name _______________________________________________________
2. Ownership:
Sole Proprietor Partnership Unincorporated Business Incorporated Business Other
On a separate sheet of paper, please provide the following information for each owner/officer, including professional
designation (e.g. Pres. John Jones, M.D.):
Name and Title
Address (Business and Home)
Phone Number (Business and Home)
Social Security Number
Date of Birth
3. Pharmacist-In-Charge (P.I.C.):
Name Kentucky License No.
P.I.C._____________________________________________________________________________________ ________________
List the names and Kentucky license numbers of any staff pharmacists licensed with Kentucky:
Name Kentucky License No.
__________________________________________________________________________________________ ________________
__________________________________________________________________________________________ ________________
__________________________________________________________________________________________ ________________
__________________________________________________________________________________________ ________________
__________________________________________________________________________________________ ________________
(Use a separate piece of paper if necessary)
Kentucky Pharmacy Regulation 201 KAR 2:205 requires pharmacists-in-charge to notify the Board within fourteen (14) calendar days of all
pharmacist-in-charge and staff pharmacist changes.
Senate Bill 88 amends KRS 315.0351 to require out-of-state pharmacies who are providing prescription medications to citizens of the
Commonwealth to have a pharmacist-in-charge who holds a Kentucky pharmacist license. This Kentucky licensed pharmacist may be any
employee pharmacist of the pharmacy.
4. Name and title of each non-pharmacist with keys to the pharmacy:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
5. Schedule of Hours:
Monday . . . . ________ A.M. to ________ P.M. Friday . . . ________ A.M. to ________ P.M.
Tuesday . . . ________ A.M. to ________ P.M. Saturday . .________ A.M. to ________ P.M.
Wednesday . ________ A.M. to ________ P.M. Sunday . . . ________ A.M. to ________ P.M.
Thursday . . . ________ A.M. to ________ P.M.
**P.I.C. must notify the Board within fourteen (14) days of any changes in scheduled hours.
6. Does pharmacy currently utilize an automated data processing system? __________Yes* __________No
*If yes, identify the source for: hardware ________________________________________ software _______________________________________
7. TYPES OF PHARMACY (INDICATE BY CIRCLING ALL THAT APPLY):
Retail Independent Retail Chain Hospital Nursing Home Nuclear
* Internet Mail Order Infusion Out-of-State Oxygen
* This must be circled if the pharmacy dispenses any prescriptions to citizens of the Commonwealth of Kentucky, in whole or in part, via the Internet [agent,
internet broker or shipper]. If Internet is circled. Section 8 must be completed.
8. Is the pharmacy VIPPS accredited? __________Yes __________No
9. Does the pharmacy dispense any prescriptions to citizens of the Commonwealth of Kentucky that have been referred
to the pharmacy, in whole or in part, by an outside agent (e.g. internet broker)? __________Yes* __________No
*If yes: Approximately how many anticipated or actual prescriptions dispensed to citizens of the Commonwealth of
Kentucky per calendar month are referred to the pharmacy by agent(s). ___________________
List the name, address, phone number, and email address of all agents:
NAME ADDRESS PHONE NUMBER EMAIL ADDRESS
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
(Use a separate piece of paper if necessary)
10. Does the pharmacy employ, contract with, or compensate directly or indirectly physicians to authorize prescriptions
for citizens of the Commonwealth of Kentucky? __________Yes* __________No
*If yes: On a separate sheet of paper, please provide the following information for all physicians:
Name
Business Address
Business Phone
Email address
DEA number
State(s) of licensure
Date of Birth
Social Security number
11. Does the pharmacy ship any prescriptions to the citizens of the Commonwealth of Kentucky under any name or
return address other than the information of the pharmacy seeking or renewing a permit provided with this
application? __________Yes* __________No
*If yes: Please provide a list of the additional pharmacy name(s) or return addresses that the pharmacy ships
prescriptions to citizens of the Commonwealth of Kentucky and why.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
(Use a separate piece of paper if necessary)
12. List the methods of deliver services (e.g. USPS, UPS, DHL, FedEx, etc) utilized to deliver prescriptions to citizens of the
Commonwealth of Kentucky and the percentage of time each service is utilized in Kentucky.
Delivery Service Utilized Percentage of Time Utilized
_____________________________________________________________________ ________________________
_____________________________________________________________________ ________________________
_____________________________________________________________________ ________________________
_____________________________________________________________________ ________________________
The Board may refuse to issue or renew a permit, or suspend, temporarily suspend, revoke, fine or reasonably restrict any permit holder for knowingly making
or causing to be made, any false, fraudulent or forged statement in connection with an application for a permit. KRS 315.121.
I hereby certify that the foregoing is true and correct and that I have read and understand Kentucky Revised Statutes Chapters 217, 218A,
and 315 and the regulations of the Kentucky Board of Pharmacy and the Cabinet for Health and Family Services pertaining to the practice of
pharmacy and certify that this pharmacy will be conducted in full compliance with all federal and state laws.
___________________________________________ _______________________
Signature of Pharmacist-in-Charge Date
I hereby certify that the above Application for Non-Resident Pharmacy Permit was signed, subscribed and sworn to before me this __________day of
_________________, 20____
Signature______________________________________
My Commission Expires_________________State of ______________________
________________________________________________________________________________________________________________________________
___________________________________________ _______________________
Signature of Owner Date
I hereby certify that the above Application for Non-Resident Pharmacy Permit was signed, subscribed and sworn to before me this__________day of
_________________, 20____
Signature____________________________________
My Commission Expires________________State of_______________________
REQUIRED DOCUMENTATION MUST BE ENCLOSED:
[FOR INITIAL APPLICATIONS ONLY]
o Completed application
o Copy of Resident Pharmacy Permit
o Copy of Last Inspection Report
o Copy of DEA Registration
o Completed Attached License Verification Form
o Sample Label of any Pharmacy Label used to ship Controlled and
Non-Controlled Substances into Kentucky
o Copy of the End-of-Day Report for the Seven (7) Business Days preceding
the application date
o Copy of notarized Memorandum of Understanding and Agreement
FORM 1 - 7/2012
KENTUCKY BOARD OF PHARMACY
State Office Building Annex, Suite 300
125 Holmes Street
Frankfort KY 40601
NON-RESIDENT PHARMACY PERMIT VERIFICATION
This form must be completed by the applicant and the Board of Pharmacy of the state in which the
applicant is located, and returned with the non-resident pharmacy permit application to the Board
office before a non-resident pharmacy permit will be issued.
Name of Pharmacy
Physical Address of Pharmacy
City State ZIP Code
Name of Pharmacist-in-Charge License Number
The following section is to be completed by the Board of Pharmacy of the state in which the applicant is located:
Is the pharmacy properly licensed or registered in your state? Yes No
Has this pharmacy been the subject of disciplinary action(s) taken by any licensing jurisdiction, government agency,
law enforcement agency or court? Yes* No
*If yes, attach a letter of explanation, a copy of the charging document/complaint and all relevant court documents.
Has the Pharmacist-in-Charge been the subject of disciplinary action(s) taken by any licensing jurisdiction, government
agency, law enforcement agency or court? Yes* No
*If yes, attach a letter of explanation, a copy of the charging document/complaint and all relevant court documents.
Printed name and title of State Official State
Signature of State Official Date
SEAL
KENTUCKY BOARD OF PHARMACY
State Office Building Annex, Suite 300
125 Holmes Street
Frankfort KY 40601
Memorandum of Understanding and Agreement
I have read, understand, and agree to abide by KRS Chapters 315, 217, and 218A; 201 KAR Chapter 2;
and 902 KAR Chapter 55. In addition, I specifically acknowledge and agree to the following:
I understand that the Board of Pharmacy ("board") may refuse to issue or renew a license or permit, or may
suspend, temporarily suspend, revoke, fine, place on probation, reprimand, reasonably restrict, or take any
combination of actions against a licensee or permit holder for knowingly making or causing to be made any
false, fraudulent, or forged statement or misrepresentation of a material fact in securing issuance or
renewal of a license or permit. KRS 315.121(1) (e)
Every out-of-state pharmacy granted an out-of-state pharmacy permit by the board shall disclose to the
board the location, names and titles of all principal corporate officers and all pharmacists who are
dispensing prescription drugs to residents of the Commonwealth. A report containing this information shall
be made to the board on an annual basis and within thirty (30) days after any change of office, corporate
officer, or pharmacist. KRS 315.0351(2)
The pharmacist-in-charge shall be responsible for providing written notification to the board within fourteen
14 days of any change in the employment of the pharmacist-in-charge, staff pharmacists, and pharmacy
hours. 201 KAR 2:205, Section 2(3)(d)
The out-of-state pharmacy shall maintain at all times a valid unexpired permit, license, or registration to
conduct the pharmacy in compliance with the laws of the jurisdiction in which it is a resident.
KRS 315.0351(3)
The out-of-state pharmacy granted a permit shall submit to the board a copy of any subsequent inspection
report on the pharmacy conducted by the regulatory or licensure body of the jurisdiction in which it is
located. KRS 315.0351(3)
Every out-of-state pharmacy granted an out-of-state pharmacy permit shall maintain records of any
controlled substances or dangerous drugs or devices dispensed to patients in Kentucky so that the records
are readily retrievable from the records of other drugs dispensed. KRS 315.0351(4)
Records for all prescriptions delivered into Kentucky shall be readily retrievable from the other prescription
records of the out-of-state pharmacy. KRS 315.0351(5)
Each out-of-state pharmacy shall, during its regular hours of operation, but not less than six (6) days per
week and for a minimum of forty (40) hours per week, provide a toll-free telephone service directly to the
pharmacist in charge of the out-of-state pharmacy and available to both the patient and each licensed and
practicing in-state pharmacist for the purpose of facilitating communication between the patient and the
Kentucky pharmacist with access to the patient's prescription records. The toll-free number shall be placed
on a label affixed to each container of drugs dispensed to patients within Kentucky. KRS 315.0351(6)

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