DIVISION OF MEDICAL QUALITY ASSURANCE BOARD OF PHARMACY 4052 BALD CYPRESS WAY, BIN #C-04 TALLAHASSEE, FLORIDA 32399-3254 (850) 245-4292 NON-RESIDENT PHARMACY APPLICATION AND INFORMATION JANUARY 2011 DH-MQA 1217, 7/10 Rule 64B16-28.XXX, F.A.C. American LegalNet, Inc. www.FormsWorkFlow.com Dear Florida Pharmacy Permit Applicant, Thank you for applying for a pharmacy permit in the State of Florida. The information in this packet has been designed to provide the essential information required to process your application in a timely manner. Your assistance in providing all required information will enable the Florida Board of Pharmacy (the board) staff to process your application as soon as possible. You are encouraged to apply as early as possible, to avoid delays due to a large volume of applicants. Florida Statutes require a completed application and fees before your application can be reviewed. Please read these instructions carefully and fully before submitting the application. You should keep a copy of the completed application and all other materials sent to the board office for your records. When you mail the completed application and fees, use the address noted in the instructions and on the application form. When your application arrives, your fees will be deposited and verified before the staff review can begin. You will receive a letter acknowledging receipt of your application. The staff will notify you within 30 days if any materials are incomplete. If you need to communicate with the board staff, you are encouraged to email the board staff at mqa_pharmacy@doh.state.fl.us, or you may at call us at (850) 245-4292. Phone calls are returned within 24 hours and emails are responded to within 48 hours during normal business hours. Our staff is committed to providing prompt and reliable information to our customers. Many procedures have been streamlined to expedite the processing of applications; we certainly welcome your comments on how our services may be improved. Sincerely, The Board of Pharmacy DH-MQA 1217, 07/10 Rule 64B16-28.XXX F.A.C. American LegalNet, Inc. www.FormsWorkFlow.com Non-Resident Pharmacy Permit Application Information Whether opening a new establishment, changing locations, or changing owners, a pharmacy permit is required prior to operating in the State of Florida. The permit application must be completed and returned to the Florida Board of Pharmacy with the required fee of $255.00. The application must have the original signatures of the owner or officer of the establishment and the Prescription Department Manager (PDM) or Pharmacist in Charge. Non-Resident Pharmacy Registration as authorized by Section 465.0156, F.S., is required for those pharmacies located outside the state and which ships, mails, or delivers a dispensed medicinal drug into this state. In order to dispense medicinal drugs into Florida, the pharmacy and the pharmacist designated as the prescription department manager or equivalent must be licensed in the state of location. If the applicant has more than $100 million dollars of business taxable assets, please submit a formal opinion letter from a Certified Public Accountant duly licensed in the state of your principle place of business affirming the corporation has more than $100 million of business taxable assets for the previous tax year. Application Processing Please read all application instructions before completing your application. 1) Please mail the application and the $255.00 application fee (check or money order made payable to the FLORIDA DEPARTMENT OF HEALTH) to the following address: Department of Health Board of Pharmacy P.O. Box 6320 Tallahassee, Florida 32314-6320 OR, use the following address if you are using express mail: Department of Health Board of Pharmacy 4052 Bald Cypress Way, Bin C-04 Tallahassee, FL 32399-3254 2) Please submit a letter of licensure verification for the facility as well as for the Pharmacy Manager from the state board of pharmacy where you are located. The letter must include: a. Original Licensure Date; b. Expiration Date; and c. Licensure Status. 3) Please submit a copy of your most recent inspection by the state board of pharmacy or the entity responsible for conducting inspections in the state where you are physically located. Within 30 days of receipt of your application and fees, the board office will notify you of the receipt of your application, any required documents, and your status. If your application is incomplete, you will be notified in writing of what is required to make your application complete. DH-MQA 1217, 07/10 Rule 64B16-28.XXX, F.A.C. 1 American LegalNet, Inc. www.FormsWorkFlow.com FLORIDA BOARD OF PHARMACY P.O. Box 6320 Tallahassee, FL 32314-6320 Telephone (850) 488-0595 http://www.doh.state.fl.us/mqa/pharmacy NON-RESIDENT PHARMACY REGISTRATION Application Type – Please choose one of the following: ____ New Establishment ($255.00 Fee) ____ Change of Location ($100.00 Fee) ____ Change of Ownership (a new permit number will be issued) ($255.00 Fee) If applicable, list existing permit number: __________________ List Federal Employer Identification Number: 1. Corporate Name Telephone Number 2. Doing Business As (d/b/a) E-Mail Address 3. Mailing Address City State Zip State Zip 4. Physical Address City 5. List Prescription Department Manager (PDM) Name License No. 6. Contact Person Start Date Signature Telephone Number 7. DEA Registration Number 8. Do you have 24 hour access to patient records? ____YES ____NO If no explain on separate sheet 9. Please provide the name, address, telephone number, and permit number of your prescription drug wholesale distributor. Name Telephone Number Permit Number Street Address City 10. Operating Hours State Zip 10a. Non-Resident Applicants Provide Toll-Free Telephone Number Below: Prescription Department Hours (______) _________- _________ Monday-Friday: Open ________ Close: ________ Saturday: Open: ________ Close: ________ Sunday: Open: ________ Close: ________ DH-MQA, 1217, 07/10 Rule 64B16-28.XXX, F.A.C. Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 11. Ownership Information a. Type of Ownership: _____Individual _____Corporation _____Partnership ______Other: _________________________________________ NOTE: IF CORPORATION OR LIMITED PARTNERSHIP YOU MUST INCLUDE WITH YOUR APPLICATION A COPY OF THE ARTICLES OF INCORPORATION ON FILE WITH THE SECRETARY OF STATE'S OFFICE WHERE THE PHARMACY IS LOCATED. b. Are the applicants, officers, directors, shareholders, members and partners over the age of 18? Yes No c. List each person having an ownership interest of 5 percent or greater and any person who, directly or indirectly, manages, oversees, or controls the operation of the applicant Attach a separate sheet if necessary. Owner/Officer-Title Date of Birth Mailing Address % of Ownership Pursuant to Section 456.0635(2), Florida Statutes, questions 12 through 18 are being asked. If you answer yes to any of the following questions, explain on a separate sheet providing accurate details and submit copies of supporting documentation. 12. Has the applicant or any principal, officer, agent, managing employee, or affiliated person of the applicant been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under Chapter 409, Chapter 817, or Chapter 893, Florida Statutes; or 21 U.S.C. ss. 801-970 or 42 U.S.C. ss.1395-1396? (If no, do not answer 13.) Yes No (You must include all misdemeanors and felonies, even if adjudication was withheld by the court, so that you would not have a record of conviction. Driving under the influence or driving while impaired is NOT a minor traffic offense for the purposes of this question.) 13. Has it been more than 15 years prior to the date of this application since the sentence and completion of any subsequent period of probation for such conviction? Yes No (If yes, explain on a separate sheet providing accurate details) 14. Has the applicant or any principal, officer, agent, managing employee, or affiliated person of the applicant ever been terminated for cause from the Florida Medicaid Program pursuant to Section 409.913, Florida Statutes? (If no, do not answer 15.) Yes No 15. If the applicant or any principal, officer, agent, managing employee, or affiliated person of the applicant has been terminated, has the applicant been reinstated and in good standing with the Florida Medicaid Program for the most recent five years? Yes No (If yes, explain on a separate sheet providing accurate details) 16. Has the applicant or any principal, officer, agent, managing employee, or affiliated person of the applicant ever been terminated for cause, pursuant to the appeals procedures established by the state or federal government, from any other state Medicaid program or the federal Medicare program? (If no, do not answer 17 and 18) Yes DH-MQA, 1217, 07/10 Rule 64B16-28.XXX, F.A.C. No (If yes, explain on a separate sheet providing accurate details) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 17. Has the applicant been in good standing with a state Medicaid program or the federal Medicare program for the most recent five years? Yes No (If yes, explain on a separate sheet providing accurate details) 18. Did the termination occur at least 20 years prior to the date of this application? Yes No (If yes, explain on a separate sheet providing accurate details) 19. Are you currently registered or permitted in any other states? If yes, provide the state, permit type, and permit number for each permit. Attach a separate sheet if necessary. Yes No State Permit Type Permit Number 20. Has the applicant, affiliated persons, partners, officer, directors, or PDM or Consultant Pharmacist of Record ever owned a pharmacy? If yes, provide the name of the pharmacy, the state where the pharmacy is located and the status of the pharmacy. Attach a separate sheet if necessary. Yes No Pharmacy Name (If yes, explain on a separate sheet providing accurate details) State Status 21. Has any disciplinary action ever been taken against any license, permit or registration issued to the applicant, affiliated persons, partners, officers, directors or PDM in this state or any other? Yes No (If yes, explain on a separate sheet providing accurate details) 22. Is there any other permit issued by the Department Health located at the physical location address on this application? Yes No (If yes, explain on a separate sheet providing accurate details) ALL QUESTIONS MUST BE ANSWERED OR YOUR APPLICATION WILL BE RETURNED ******************************************************************************************************************************** Section 456.013(1), F.S., requires that applicants supplement their applications as needed to reflect any material change in any circumstances or conditions stated in the application, which takes place between the initial filing of the application and the final grant or denial of the license, which might affect the decision of the department. I certify that the statements contained in this application are true, complete, and correct and I agree that said statements shall form the basis of my application and I do authorize the Florida Board of Pharmacy to make any investigations that they deem appropriate and to secure any additional information concerning me, and I further authorize them to furnish any information they may have or have in the future concerning me to any person, corporation, institution, association, board, or any municipal, county, state, or federal governmental agencies or units, and I understand according to the Florida Board of Pharmacy Statutes that a Pharmacy Permit may be revoked or suspended for presenting any false, fraudulent, or forged statement, certificate, diploma, or other thing, in connection with an application for a license or permit, as set forth in Section 465.015(2)(a), F.S. I hereby have sworn that these statements are true and correct and recognize that providing false information may result in disciplinary action against my license or criminal penalties pursuant to sections 465.016, 775.082, 775.083, and 775.084, F.S. SIGNATURE _____________________________________________ TITLE ________________________DATE_________________ Owner/Officer DH-MQA, 1217, 07/10 Rule 64B16-28.XXX, F.A.C. Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com PHARMACY PERMIT APPLICATION CHECKLIST Keep a copy of the completed application for your records. It is recommended that you use the following checklist to help ensure that your application is complete. Failure to attach any required document, or to have required documentation sent to the Board, will result in an incomplete application. Final approval for inspection can not be granted until the application is complete. Faxed applications will not be accepted. NON-RESIDENT PHARMACY PERMIT ______ Application Completed (all questions answered) ______ Application signed ______ Pharmacy Manager or Consultant Listed with Signature ______ Pharmacy Manager and Pharmacy License Verification from the resident state ______ $255.00 Fee Attached (Permit fee includes $250 application fee and $5.00 unlicensed activity fee) ______ Certificate of Status for the Corporation from the Secretary of State ______ Bill of Sale is required for Change of Ownership ______ Recent Inspection Report DH-MQA, 1217, 07/10 Rule 64B16-28.XXX, F.A.C. Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com