Louisiana Board of Pharmacy 3388 Brentwood Drive Baton Rouge, Louisiana 70809-1700 www.pharmacy.la.gov Application for Louisiana Pharmacy Permit Located Out-of-State Notices • Chapter 11 of the Board’s rules enumerates the minimum requirements for pharmacies and prescription departments, and Chapter 23 identifies the additional requirements for non-resident or out-of-state pharmacies. All of our laws and rules may be accessed on our website, at www.pharmacy.la.gov. • The Louisiana Board of Pharmacy requires compliance with current federal standards applicable to sterile compounding activities (USP Chapter 797). Pharmacies electing to engage in such activities for the benefit of Louisiana residents shall demonstrate their compliance with current federal standards by the attachment of appropriate documentation to their application. • We encourage you to type your entries on the application. If you choose to print, please do so legibly using blue or black ink. Do not use pencil. Applications completed in pencil, or those with illegible entries, shall be returned to the applicant’s designated contact person. • Please do not re-format the application to accommodate your entries. Applications reformatted from the posted version shall be returned to the applicant’s designated contact person. • Please do not use entries such as “See attached”; an appropriate entry shall be made in each section. Incomplete applications shall be returned to the applicant’s designated contact person. • Blank applications may be copied as needed; please use standard copy paper. Applications completed or reproduced on thermal or waxy paper will not be accepted, and they shall be returned to the applicant’s designated contact person. • We encourage you to review your application and attachments prior to submission to the Board. Our experience shows the most common reason to return an application is for incomplete documents. This will only delay the processing of your application. • The application shall be submitted to the Board office, at the address noted hereinabove, at least thirty (30) days prior to the anticipated opening date of the new pharmacy or the ownership transfer. • Your application and fee will be valid for up to one year after the date of its receipt at the Board office. If the permit has not been issued by that date, the application shall be voided and the fee shall be forfeited. • Pharmacy permits expire at midnight on December 31 of every calendar year, regardless of the date of issuance. Pharmacies may not operate with expired permits. Form No. 52 Page 1 of 6 Rev 07-01-2011 American LegalNet, Inc. www.FormsWorkFlow.com Louisiana Board of Pharmacy 3388 Brentwood Drive Baton Rouge, Louisiana 70808-2537 Telephone 225.922.0852 ~ Facsimile 225.925.6499 Website: www.pharmacy.la.gov ~ Email: info@pharmacy.la.gov Application for Louisiana Pharmacy Permit Located Out-of-State (Complete this application for pharmacies located outside of Louisiana.) Please type all entries; if printing, please do so legibly using blue or black ink. All checks or money orders for the $175.00 fee shall be made payable to “Louisiana Board of Pharmacy.” Mail this application, all attachments, and fee to the address noted at the top of this page. Incomplete applications will be returned to the contact person. Section 1 – Reason for Application [select one] & Date of Opening _____ New Pharmacy Permit _____ Ownership Transfer Anticipated Date of Opening _______________________ Section 2 – Pharmacy Information Name (d/b/a) _____________________________________________________________________________________________ Physical Address __________________________________________________________________________________________ City, Parish, State, ZIP _____________________________________________________________________________________ Telephone ___________________________ Facsimile ___________________________ Email __________________________ Toll-free Telephone ____________________________ Resident State Pharmacy Permit No. _________________ Expiration Date ____________________ DEA Registration No. _________________________ Expiration Date ______________________ Mailing Address __________________________________________________________________________________________ City, Parish, State, ZIP _____________________________________________________________________________________ Has this pharmacy ever been the subject of any disciplinary or other adverse action by any other licensing agency, or by any other government agency, or by any local, state, or federal law enforcement agency, or by any local, state, or federal court? _____ Yes _____ No If you answered “Yes” to this question, please attach a letter of explanation as well as a certified copy of the final disposition for each incident. If charges were dismissed, please provide a letter from the appropriate authority confirming dismissal of the charges. Your failure to disclose any prior disciplinary or adverse action or criminal history may result in the denial of this application or disciplinary action against the permit. Section 3 – Applicant’s Designated Contact Person [for processing of application] Name _________________________________________________________________________________________________ Company ______________________________________________________________________________________________ Address _______________________________________________________________________________________________ City, State, ZIP __________________________________________________________________________________________ Telephone _______________________ Facsimile ___________________ Email _____________________________________ For Board Use Only: Date application received: ____________________ Check / M.O. # __________________________ Amt. _________________ Interview Required: Yes / No Form No. 52 Compliance Officer: ___________ Page 2 of 6 Permit No. ____________ Issued: ___________ Rev 07-01-2011 American LegalNet, Inc. www.FormsWorkFlow.com Section 4 – Pharmacy Ownership [select one] Please identify the legal entity which owns the pharmacy identified in Section 2. _____ Individual Name: ________________________________________________________________________ _____ Partnership Name: ________________________________________________________________________ _____ Corporation Name: ________________________________________________________________________ _____ LLC Name: ________________________________________________________________________ _____ Association Name: ________________________________________________________________________ _____ Government Name: ________________________________________________________________________ _____ Other [explain] Name: ________________________________________________________________________ Federal Employment Identification Number (FEIN) of this legal entity: _______________________________________________ Section 5 – Owner’s Address Please enter the business address of the entity identified in Section 4. Physical Address __________________________________________________________________________________________ City, State, ZIP ___________________________________________________________________________________________ Telephone ________________ Facsimile ________________ Email ___________________ Website ______________________ Mailing Address ___________________________________________________________________________________________ City, State, ZIP ____________________________________________________________________________________________ Section 6 – Ownership of Other Pharmacies Does the entity identified in Section 4 currently own any other pharmacy? _____ Yes _____ No If the entity identified in Section 4 does own any other pharmacy in any state, please attach an itemized listing of all such pharmacies. For each such entry, please provide the name and physical address of the pharmacy, the permit number of that pharmacy, and whether or not that pharmacy has ever been sanctioned or disciplined by any state board of pharmacy or by any local, state, or federal government agency or by any local, state, or federal court. Section 7 – Owner’s Managing Officer The person identified in this section shall be the individual authorized by the owner(s) to act on their behalf and shall be responsible to the Board for the proper operation of the pharmacy in compliance with all laws and regulations. Name __________________________________________________________________________________________________ Position/Title _____________________________________________________________________________________________ Mailing Address __________________________________________________________________________________________ City, State, ZIP ___________________________________________________________________________________________ Telephone _______________________ Facsimile _______________________ Email __________________________________ Have you ever been arrested, indicted, or charged with any crimes in any state? _____ No _____ Yes Have you ever been the subject of any disciplinary action by any government agency, or have you ever been the subject of any legal or other adverse action from any law enforcement agency or any local, state, or federal court? _____ No _____ Yes Are you currently charged with the commission of a felony in any state? _____ No _____ Yes Have you ever been convicted of a felony in any state? _____ No _____ Yes If you answered “Yes” to any of the four questions above, please attach a letter of explanation as well as a certified copy of the final disposition for each incident. If charges were dismissed, please provide a letter from the appropriate authority confirming dismissal of the charges. Your failure to disclose any prior disciplinary or criminal history may result in the denial of this application or disciplinary action against the permit. Form No. 52 Page 3 of 6 Rev 07-01-2011 American LegalNet, Inc. www.FormsWorkFlow.com Section 8 – Registered Agent for Service of Process In the absence of a designated agent, the applicant will be deemed to have designated the Louisiana Secretary of State to be its agent, upon whom may be served all legal process in any action or proceeding against the pharmacy. Name ________________________________________________________________________________________________ Mailing Address ________________________________________________________________________________________ City, State, ZIP _________________________________________________________________________________________ Section 9 – Ownership Transfer of an Existing Pharmacy If this option was selected in Section 1, please identify the existing pharmacy as it appears on that pharmacy’s permit. Pharmacy Name (d/b/a) ___________________________________________________________________________________ Physical Address ________________________________________________________________________________________ City, State, ZIP __________________________________________________________________________________________ Existing Louisiana Pharmacy Permit No. __________________ DEA Registration No. __________________ Section 10 – Pharmacist-in-Charge No person may serve as the pharmacist-in-charge (PIC) of a Louisiana pharmacy permit until the Board has received his properly executed Affidavit of Acknowledgement and Acceptance of Responsibility of Pharmacist-in-Charge. Name ________________________________________________________________________________________________ Mailing Address ________________________________________________________________________________________ City, State, ZIP _________________________________________________________________________________________ Telephone ________________________ Facsimile ______________________ Email _________________________________ Resident State Pharmacist License No. _________________________ Louisiana Pharmacist License No. __________________________________________________________________________ Do you serve as the PIC of any other Louisiana pharmacy permit? _____ No _____ Yes [Permit No. _________] Have you ever been arrested, indicted, or charged with any crimes in any state? _____ No _____ Yes Have you ever been the subject of any disciplinary action by any government agency, or have you ever been the subject of any legal or other adverse action from any law enforcement agency or any local, state, or federal court? _____ No _____ Yes Are you currently charged with the commission of a felony in any state? _____ No _____ Yes Have you ever been convicted of a felony in any state? _____ No _____ Yes If you answered “Yes” to any of the four questions above, please attach a letter of explanation as well as a certified copy of the final disposition for each incident. If charges were dismissed, please provide a letter from the appropriate authority confirming dismissal of the charges. Your failure to disclose any prior disciplinary or criminal history may result in the denial of this application or disciplinary action against the permit. Section 11 – Special Services for Louisiana Residents Will this pharmacy perform any non-sterile compounding services? _____ No _____ Yes Will this pharmacy perform any sterile compounding services? _____ No _____ Yes** Will this pharmacy utilize an Automated Medication System (AMS)? _____ No _____ Yes Will this pharmacy dispense or distribute any prescription medical devices? _____ No _____ Yes Will this pharmacy dispense or distribute any medical gases? _____ No _____ Yes Will this pharmacy utilize a website to facilitate its dispensing operations? _____ No _____ Yes If so, is the site certified by VIPPS? _____ No _____ Yes Location of server: _______________________________ ** Please attach evidence of compliance with current federal standards for sterile compounding activities (USP Chapter 797).** Form No. 52 Page 4 of 6 Rev 07-01-2011 American LegalNet, Inc. www.FormsWorkFlow.com Section 12 – Required Attachments • All Pharmacies Identify all individuals holding an ownership interest, as well as their percentage or fraction thereof, in the entity identified in Section 4. For each person so identified, please provide their full name, date of birth, Social Security number, addresses (business and home), and telephone numbers (business and home). Further, if any of these individuals hold a professional license or credential from any state government agency, please indicate their designation and provide a copy of the license or credential. Finally, please indicate whether that license or credential has ever been sanctioned or disciplined, and if so, provide a copy of that agency decision. Identify all officers, partners, and board members, along with their position titles. For each person so identified, please provide their full name, date of birth, Social Security number, addresses (business and home), and telephone numbers (business and home). Further, if any of these individuals hold a professional license or credential from any state government agency, please indicate their designation and provide a copy of the license or credential. Finally, please indicate whether that license or credential has ever been sanctioned or disciplined, and if so, provide a copy of that agency decision. With respect to the applicant’s pharmacy permit from the resident state board of pharmacy, please attach a copy of that credential, a copy of the most recent inspection report, and a letter from the resident state board of pharmacy attesting to the current status of the resident state permit, with information as to whether or not that permit has ever been sanctioned or disciplined by that agency, and if so, a copy of that agency decision. With respect to the compounding of sterile preparations for Louisiana residents, attach evidence of compliance with current federal standards (USP Chapter 797). • Ownership Transfers By the attached letter, the owner of the existing pharmacy shall confirm the pending sale to the applicant, as well as the anticipated transfer date. Section 13 – Attestations By their signatures below, the owner’s managing officer and the pharmacist-in-charge attest to their knowledge and agreement with the following statements: We understand and agree that our application and fee will be valid for up to one year following the date of receipt in the Board’s office. We understand and agree that no person shall open, establish, operate, or maintain a pharmacy or dispense prescriptions to Louisiana residents unless the pharmacy is issued a permit by the Board. We understand and agree that no permit to operate a pharmacy shall be granted or renewed unless evidence satisfactory to the Board ensures that a pharmacist will be on duty during normal business hours. We understand and agree that the parties executing this application may be required to personally appear before the Board prior to any decision on the permit application. We understand and agree that no person shall carry on, conduct, or transact business under a name which contains a part thereof the words “pharmacist”, “pharmacy”, “apothecary”, “apothecary shop”, “chemist’s shop”, “drug store”, “druggist”, “drugs”, or any word or words of similar or like import, or in any manner by advertisement, circular, poster, sign, or otherwise describe or refer to a place of business by the terms of “pharmacy”, “apothecary”, “apothecary shop”, “chemist’s shop”, “drug store”, “drugs”, or any word or words of similar or like import, unless the place of business is validly permitted by the Board. We understand and agree a prescription issued solely on the results of answers to an electronic questionnaire, in the absence of a documented patient evaluation including a physical examination by the prescriber, is issued outside the context of a valid physician-patient relationship, and is not a valid prescription, and further, that a pharmacist who dispenses prescription drugs in violation of Section 2515 of the Board’s rules is not acting in the best interest of the patient and is dispensing outside the course of the professional practice of pharmacy. We understand and agree that a permit to operate a pharmacy shall not be transferable to a new owner. We understand and agree that this pharmacy shall be operated in compliance with the Louisiana Pharmacy Practice Act (La. R.S. 37:1161 to 1250) and the professional and occupational standards found in Part LIII of Title 46 of the Louisiana Administrative Code, as well as all other federal and state laws and rules that may be applicable to the scope of services rendered to Louisiana residents at this pharmacy. Form No. 52 Page 5 of 6 Rev 07-01-2011 American LegalNet, Inc. www.FormsWorkFlow.com Owner’s Managing Officer I hereby certify that all of the foregoing and attached information is true and correct to the best of my knowledge, and further, that I have read, do understand, and do agree with the provisions referenced above in this section, and further, that this pharmacy will be operated in full compliance with all federal and state laws and regulations pertaining to the practice of pharmacy. _____________________________ ________________________ Signature of Owner’s Managing Officer Date I hereby certify that the Attestations of the Owner’s Managing Officer were signed, subscribed, and sworn to before me on this ________ day of _________________ in the year __________. ____________________________ Signature of Notary Public Seal Required ____________________________ Parish or County ____________________________ Expiration Date of Commission Pharmacist-in-Charge I hereby certify that all of the foregoing and attached information is true and correct to the best of my knowledge, and further, that I have read, do understand, and do agree with the provisions referenced above in this section, and further, that this pharmacy will be operated in full compliance with all federal and state laws and regulations pertaining to the practice of pharmacy. _____________________________ ________________________ Signature of Pharmacist-in-Charge Date I hereby certify that the Attestations of the Pharmacist-in-Charge were signed, subscribed, and sworn to before me on this ________ day of _________________ in the year __________. ____________________________ Signature of Notary Public Seal Required ____________________________ Parish or County ____________________________ Expiration Date of Commission Form No. 52 Page 6 of 6 Rev 07-01-2011 American LegalNet, Inc. www.FormsWorkFlow.com