CERTIFIED PHARMACIES REVISED 05/07,12/07, 9/08, 3/09, 7/09, 03/10, 08/10, 4/12, 6/12 Page 1 of 11 MONTANA BOARD OF PHARMACY P. O. Box 200513 (301 S PARK, 4TH FLOOR HELENA MT 59601- Delivery) Helena, Montana 59620-0513 PHONE (406) 841-2355 OR 2356 FAX (406) 841-2344 E-MAIL: dlibsdpha@mt.gov WEBSITE: www.pharmacy.mt.gov ILLEGIBLE AND INCOMPLETE APPLICATIONS WILL BE RETURNED. (Please allow 30 days for processing from the date that the Board has a complete routine application) A BUSINESS CANNOT OPERATE IN MONTANA IN ANY MANNER WITHOUT AN ACTIVE MONTANA LICENSE LICENSE REQUIREMENTS FOR COMMUNITY, INSTITUTIONAL, CLOSED DOOR, TELEPHARMACY, AND HOME INFUSION PHARMACY Owner of the pharmacy is a registered pharmacist in good standing in the state of Montana OR The manager or supervisor of the pharmacy is a registered pharmacist in good standing in the state of Montana and that the pharmacist will be actively and regularly engaged and employed in and responsible for the management, supervision and operation of such pharmacy The license registers the pharmacy to which it is issued and is not transferable. It is issued on the application of the registered pharmacist in charge, and which contains the sworn statement that the pharmacy will be operated in accordance with the provisions of the law To operate, maintain, open or establish more than one pharmacy, separate applications shall be made and separate licenses issued for each Upon closure of a certified pharmacy, the original license becomes void and must be surrendered to the Board within ten days. Each institutional pharmacy must be directed by a pharmacist-in-charge who is licensed to engage in the practice of pharmacy in the state of Montana and who is responsible for the storage, compounding, repackaging, dispensing and distribution of drugs within the facility. Depending upon the needs of the facility, pharmacy services may be provided on a full or part-time basis, with a mechanism for emergency service provided at all times. Contractual providers of pharmacy services shall meet the same requirements as pharmacies located within the institution. Registered pharmacy technicians or technicians-in-training may be utilized pursuant to the written policies and procedures of the institution pharmacy. Exemptions to established ratios as defined in ARM 24.174.711 may be granted with Board approval. Each home infusion pharmacy must be licensed with both the Board of Pharmacy and with the Department of Health and Human Services (DPHHS). Information about licensing with DPHHS can be obtained at www.dphhs.mt.gov or by calling (406) 444-1742 Telepharmacy: A remote telepharmacy site shall be connected to its parent pharmacy via computer, video and audio link. A site cannot be licensed as a remote telepharmacy site if it is located within a ten mile radius of an existing pharmacy. The registered pharmacy technician present at the remote telepharmacy site must be currently registered with the Board and have at least six months of active experience as a pharmacy technician. FEES $400.00 - (Non-Refundable) Application Fee $ 75.00 - (Non-Refundable) Dispense under the Montana Dangerous Drug Act $200.00 - (Non-Refundable) Pharmacy Technician Utilization Plan American LegalNet, Inc. www.FormsWorkFlow.com CERTIFIED PHARMACIES REVISED 05/07, 12/07, 9/08, 3/09, 7/09, 03/10, 08/10, 4/12, 6/12 Page 2 of 11 DOCUMENTS The following documents must be submitted to the Board office in order to complete your license application. Please make 8-1/2"x11" copies of the following and submit with your application. A schematic drawing (floor plan) and security of the pharmacy area ADDITIONAL FORMS TO BE SUBMITTED FOR AN APPLICATION TO BE COMPLETE Complete the Dangerous Drug Act application if this pharmacy will be dispensing controlled substances, Complete the Technician Utilization Plan application if pharmacy technicians will be employed in this facility, Complete the non-owner pharmacist agreement if applicable. APPLICATION PROCEDURES When the application file is complete, it will be processed and considered by Board staff for permanent licensure. The applicant will be notified if additional information is required or if required to appear before the Board for an interview. If the application is considered a non-routine application, there may be a delay in processing of the application. You may be requested to provide additional information, or make a personal appearance before the Board during a regularly scheduled Board meeting and/or the application may require Board consideration. Non-routine applications may take up to 120 days to process. Keep the Board office informed at all times of any address changes, changes in license status and complaints or proposed disciplinary action. This is essential for timely processing of applications and subsequent licensure. PROCESSING PROCEDURES Once a routine application is complete, the application takes up to 30 days to process from the time it is received in the Board office. The applicant will be notified in writing of any deficient or missing items from the application file. Once a routine application is processed and approved a permanent license will be issued. ADDITIONAL LAW AND RULE INFORMATION According to ARM 24.174.814 Security of Pharmacy, each pharmacist, while on duty shall be responsible for the security of the pharmacy, including provisions for effective control against theft or diversion of drugs. A Schedule II controlled substance perpetual inventory shall be maintained and routinely reconciled in all pharmacies. The pharmacy shall be secured at all times by either a physical barrier with suitable locks and/or an electronic barrier to detect entry by unauthorized persons at any time. Such barrier shall be approved by the Board or its designee before being put into use. Prescription and other patient health care information shall be maintained in a manner that protects the integrity and confidentiality of such information as provided by the rules of the Board. For information with regard to the processing of this application or other concerns please contact the Board of Pharmacy staff at (406) 841-2355 or 2356 or email us at dlibsdpha@mt.gov PLEASE BE SURE TO REVIEW THE MONTANA LAWS AND RULES ON OUR WEBSITE www.pharmacy.mt.gov American LegalNet, Inc. www.FormsWorkFlow.com CERTIFIED PHARMACIES REVISED 05/07, 12/07, 9/08, 3/09, 7/09, 03/10, 08/10, 4/12, 6/12 Page 3 of 11 MONTANA BOARD OF PHARMACY P. O. Box 200513 (301 S PARK, 4TH FLOOR HELENA MT 59601 - Delivery) Helena, Montana 59620-0513 PHONE (406) 841-2356 FAX (406) 841-2344 E-MAIL: dlibsdpha@mt.gov WEBSITE: www.pharmacy.mt.gov Application for Licensure as: 1. Institutional Telepharmacy NAME: 2. Community MAILING ADDRESS: Street or PO Box # 3. City and State Zip PHYSICAL ADDRESS EMAIL ADDRESS: 4. TELEPHONE: FAX 5. TAX ID NUMBER 6. PHARMACIST-IN-CHARGE MT LICENSE # Address City State Zip Code Phone 7. Fax PLEASE LIST LICENSE NUMBER AND NAME OF BUSINESS IF PREVIOUSLY LICENSED IN MONTANA AND APPROXIMATE DATE OF CLOSURE FOR THIS LICENSE. REASON FOR CLOSURE: Location Ownership Other 8. DESCRIBE THE SCOPE AND TYPE OF SERVICES TO BE PROVIDED BY THIS PHARMACY 9. CHECK THE TYPE OF OWNERSHIP OR OPERATION AND ATTACH THE REQUIRED INFORMATION Sole Proprietor 10. Partnership Corporation Other Has this business or the person in charge of this business who is listed on the application ever had an application for a professional or occupational license refused or denied? If yes, please attach a detailed explanation and provide supporting documentation from the source. Yes No American LegalNet, Inc. www.FormsWorkFlow.com CERTIFIED PHARMACIES REVISED 05/07, 12/07, 9/08, 3/09,7/09, 03/10, 08/10, 4/12, 6/12 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Page 4 of 11 Has this business or the person in charge of this business who is listed on the application ever withdrawn an application for licensure prior to the licensing agency's decision regarding your application? If yes, please attach a detailed explanation and provide supporting documentation from the source. Yes No Has the person in charge of this business who is listed on this application ever been denied the privilege of taking an examination required for any professional or occupational license? If yes, please attach a detailed explanation and provide supporting documentation from the source. Yes No Has the person in charge of this business who is listed on this application ever withdrawn or been suspended, placed on probation, expelled or requested to resign from any postsecondary educational program? If yes, please attach a detailed explanation and provide supporting documentation from the source. Yes No Has the person in charge of this business who is listed on this application ever requested temporary or permanent leave of absence, been placed on probation, restricted, suspended, revoked, allowed to resign, or otherwise acted against by any professional or occupational education program (i.e., residency, internship, apprenticeship, etc)? If yes, please attach a detailed explanation and provide supporting documentation from the source. Yes No Has a licensing agency initiated or completed disciplinary action against this business or the person in charge of this business who is listed on this application? If yes, please provide agency documents including the complaint, initiating documents, orders, final orders, stipulations and consent and/or settlement agreements directly from the source. Yes No Has this business or the person in charge of this business who is listed on this application voluntarily surrendered, cancelled, forfeited, failed to renew a professional or occupational license in anticipation of or during an investigation or disciplinary proceeding or action? If yes, please attach a detailed explanation and provide supporting documentation from the source. Yes No Has a complaint ever been made against this business or person in charge of this business who is listed on this application with a professional or occupational licensing agency? If yes, please attach a detailed explanation and provide supporting documentation from the source. Yes No Yes No Yes No Yes No Has this business or the person in charge of this business who is listed on this application ever been the subject of any sanction or action, denial, suspension, revocation, restriction or termination regarding hospital, facility or staff privileges; health maintenance organization participation, third party provider or Medicare/Medicaid participation; or any other privileges? If yes, please attach a detailed explanation and provide supporting documentation from the source. Has this business or the person in charge of this business who is listed on this application ever been censured, expelled, denied membership or asked to resign from a professional organization related to the profession or occupation? If yes, please attach a detailed explanation and provide documentation from the source. Has this business or the person in charge of this business who is listed on this application ever been the subject of any sanction or action, denial, suspension, revocation, restriction or termination regarding the ability to prescribe, dispense or administer drugs including controlled substances? If yes, please attach a detailed explanation and provide documentation from the source. American LegalNet, Inc. www.FormsWorkFlow.com CERTIFIED PHARMACIES REVISED 05/07, 12/07, 9/08, 3/09, 7/09, 03/10, 08/10, 4/12, 6/12 21. 22. 23. 24. 25. 26. Page 5 of 11 Does this business or the person in charge of this business who is listed on this application have any initiated or completed action against you by any state, federal, tribal, or foreign licensing jurisdiction? (For example: Drug Enforcement Agency; Alcohol, Tobacco and Firearms; Homeland Security; Indian Health Service, etc) If yes, please attach a detailed explanation and provide documentation from the source. Yes Yes Has the person in charge of this business who is listed on this application ever been court-martialled or discharged other than honorably from any branch of the armed service? If yes, attach a detailed explanation and documentation for the source. No Yes Has the person in charge of this business who is listed on this application ever been diagnosed with a physical condition or mental health disorder involving potential health risk to the public? If yes, please provide a detailed explanation. No Yes Has the person in charge of this business who is listed on this application ever been diagnosed with chemical dependency or another addiction, or participated in a chemical dependency or other addiction treatment program? If yes, please attach a detailed explanation and provide documentation regarding evaluations, diagnosis, treatment recommendations and monitoring from the source. No Yes Does this business or the person in charge of this business who is listed on the application ever been convicted of a misdemeanor or felony crime or have a pending criminal charge? “Convicted” for the purposes of this question includes a conviction under appeal, guilty plea, no contest plea, and/or forfeiture of bond. “A pending criminal charge” for the purposes of this question includes a deferred imposition of sentence and/or deferred prosecution. If answered yes, a detailed explanation must be submitted on the events AND the charging documents and final judgments or orders of dismissal. You must report but may omit documentation for: (1) misdemeanor traffic violations older than 10 years ago and that resulted in fines of less than $200; and (2) convictions prior to your 18th birthday unless you were tried as an adult. No Yes Have any civil legal proceedings been filed against this business or the person in charge of this business who is listed on this application by a (patient/client), (former patient/client) or employer/employee? If yes, attach a detailed explanation and documentation from the source including initiating document(s) and documentation of final disposition. No No DECLARATION I authorize the release of information concerning my education, training, record, character, license history and competence to practice, by anyone who might possess such information, to the Montana Board of Pharmacy. I hereby declare under penalty of perjury the information included in this application to be true and complete to the best of my knowledge. In signing this application, I am aware that a false statement or evasive answer to any question may lead to denial of this application or subsequent revocation of licensure on ethical grounds. I have read and will abide by the current licensure statutes and rules of the State of Montana governing the profession. I will abide by the current laws and rules that govern my practice. Signature of Applicant Date American LegalNet, Inc. www.FormsWorkFlow.com CERTIFIED PHARMACIES REVISED 05/07, 12/07, 9/08, 3/09, 7/09, 03/10, 08/10, 4/12 Page 6 of 11 MONTANA BOARD OF PHARMACY P. O. Box 200513 TH FLOOR HELENA MT 59601 - Delivery) (301 S PARK, 4 Helena, Montana 59620-0513 PHONE (406) 841-2356 or 2355 FAX (406) 841-2344 E-MAIL: dlibsdpha@mt.gov WEBSITE: www.pharmacy.mt.gov STATEMENT OF PHARMACIST-IN-CHARGE For the purposes of satisfying the requirements of ARM 24.174.805 or ARM 24.174.1003(1), the following agreement has been entered into and submitted to the Montana Board of Pharmacy: Name of Pharmacy License Number Address Name of Pharmacist-in-Charge City (Please Print) State Zip Code Owner of Pharmacy (Please complete "Non-Pharmacist-Owner agreement" if owner of pharmacy is different than P.I.C.) The signature below indicates that the individual is the Pharmacist-in-Charge of the above named Pharmacy and will be the Pharmacist-in-Charge until the present license expires; that if the undersigned ceases to be Pharmacist-in-Charge prior to the expiration of the license, the undersigned will notify the Board of Pharmacy of such fact and failure to do so may be cause for suspension or revocation of Pharmacist's license; that the undersigned agrees to fully and promptly comply with the applicable federal laws, laws of the State of Montana, and the rules and regulations of the Board of Pharmacy governing this application, applicant's business, and the sale of permitted drugs, pharmaceuticals, and commodities. 24.174.805 CHANGE OF PHARMACIST-IN-CHARGE (1) When the pharmacist-in-charge of a pharmacy leaves the employment of such pharmacy, the pharmacist will be held responsible for the proper notification to the board of such termination of services. (2) Within 72 hours of termination of services of the pharmacist-in-charge, a new pharmacist-incharge must be designated and an affidavit filed with the board. The license will then be updated to indicate the name of the new pharmacist-in-charge. Signature ______________________________________________ *Please retain a copy of this form in the pharmacy and send the original to the Board office* American LegalNet, Inc. www.FormsWorkFlow.com CERTIFIED PHARMACIES REVISED 05/07, 12/07, 9/08, 3/09, 7/09, 03/10, 08/10, 4/12 Page 7 of 11 MONTANA BOARD OF PHARMACY P. O. Box 200513 TH FLOOR HELENA MT 59601 - Delivery) (301 S PARK, 4 Helena, Montana 59620-0513 PHONE (406) 841-2356 or 2355 FAX (406) 841-2344 E-MAIL: dlibsdpha@mt.gov WEBSITE: www.pharmacy.mt.gov PHARMACIST-IN-CHARGE AGREEMENT (NON-PHARMACIST OWNER) For purposes of satisfying the intent of 24.174.805 ARM, or 24.174.1003(1), the following agreement has been entered into and submitted to the Montana Board of Pharmacy, PO Box 200513, Helena, MT 59620-0513: I, _____________________________________________________, duly designated agent for the __________________________________________(owner/corporation) do hereby vest exclusive authority in ____________________________________________, a licensed pharmacist and Pharmacist-in-Charge for the ____________________________ pharmacy, pharmacy license number ___________ to perform as follows: That ____________________________________, R.Ph., license number ________, shall have exclusive authority to make and implement any decision which may directly or indirectly involve compliance with any of the provisions of Title 37, Chapter 7, Montana Code Annotated and Chapter 174 of the Administrative Rules of Montana. That the parties hereto expressly agree and understand that in no event shall any person or persons, by virtue of his or their position in the corporation or for any other reason, substitute his or their judgment for that of the pharmacist-in charge on matters involving the aforementioned compliance; that the parties further agree that the continued right of the corporation to own and operate this pharmacy is contingent upon the existence and implementation of this agreement; and that the corporation agrees and understands that at such time as a new pharmacist-in-charge is designated, that a new agreement must be executed with that person and submitted to the Montana Board of Pharmacy. Signed and dated the _______ day of ____________________, 20___. _______________________________________ Agent for the Corporation _______________________________________ Pharmacist-in-Charge *Please retain a copy of this form and send the original to the Board office* American LegalNet, Inc. www.FormsWorkFlow.com CERTIFIED PHARMACIES REVISED 05/07, 12/07, 9/08, 3/09, 7/09, 03/10, 08/10, 4/12, 6/12 Page 8 of 11 MONTANA BOARD OF PHARMACY P. O. Box 200513 (301 S PARK, 4TH FLOOR HELENA MT 59601 - Delivery) Helena, Montana 59620-0513 PHONE (406) 841-2356 FAX (406) 841-2344 E-MAIL: dlibsdpha@mt.gov WEBSITE: www.pharmacy.mt.gov APPLICATION FOR REGISTRATION UNDER THE MONTANA DANGEROUS DRUG ACT Dispense Business Name: Authorized Individual: Address City State Telephone Number Zip Code Fax Number Montana License Number if already licensed and adding dispensing to license: DEA Registration Number Federal Tax I.D. No. Signature Date (Signature of applicant or authorized individual) Title NOTE: The application for DEA Number may be obtained at www.dea.gov DEA will be notified when a Montana Pharmacy license has been issued American LegalNet, Inc. www.FormsWorkFlow.com CERTIFIED PHARMACIES REVISED 05/07, 12/07, 9/08, 3/09, 7/09, 03/10, 08/10, 4/12 Page 9 of 11 MONTANA BOARD OF PHARMACY P. O. Box 200513 (301 S PARK, 4TH FLOOR HELENA MT 59601 - Delivery) Helena, Montana 59620-0513 PHONE (406) 841-2356 FAX (406) 841-2344 E-MAIL: dlibsdpha@mt.gov WEBSITE: www.pharmacy.mt.gov PHARMACY TECHNICIAN UTILIZATION PLAN LICENSE REQUIREMENTS Summary of the utilization plan to include requirements set forth in 24.174.712 ARM; and 37-7-307, 37-7-308 and 37-7-309, MCA: Name and qualifications of the supervising pharmacist(s) Nature and location of the supervising pharmacist's pharmacy practice Summary of the tasks delegated by the pharmacist and the methods by which a supervising pharmacist may verify and document tasks. "Verify" means the personal confirmation by a supervising pharmacist of the correctness of the tasks undertaken by the pharmacy technician. FEES $200.00 (Non-Refundable) - Application Fee **Make check or money order payable to the Montana Board of Pharmacy** DOCUMENTS The following documents must be submitted to the Board office in order to complete your license application. Please make 8 1/2"x11" copies of the following and submit with your application: Copy of the Technician Utilization Plan APPLICATION PROCEDURES When the application file is complete, it will be processed and considered by Board staff for approval. The applicant may be notified if additional information is required to appear before the Board for an interview. If the application is considered a non-routine application, there may be a delay in processing of the application. You may be requested to provide additional information, or make a personal appearance before the Board during a regularly scheduled Board meeting and/or the application may require Board consideration. Non-routine applications may take up to 120 days to process. Keep the Board office informed at all times of any address changes, changes in license status and complaints or proposed disciplinary action. This is essential for timely processing of applications and subsequent licensure. PROCESSING PROCEDURES Once a routine application is complete, the application takes up to 5 days to process from the time it is received in the Board office. The applicant will be notified in writing of any deficient or missing items from the application file. ADDITIONAL STATUTE AND RULE INFORMATION Keep on file in the pharmacy a copy of the utilization plan for inspection by the Board Annual review of the utilization plan and provide documentation to the Board that the plan accurately reflects the current use of the services of a pharmacy technician or auxiliary. For information with regard to the processing of this application or other concerns please contact the Board of Pharmacy staff at 406-841-2355 or 2356 or email us at dlibsdpha@mt.gov American LegalNet, Inc. www.FormsWorkFlow.com CERTIFIED PHARMACIES REVISED 05/07, 12/07, 9/08, 3/09, 7/09, 03/10, 08/10, 4/12 Page 10 of 11 MONTANA BOARD OF PHARMACY P. O. Box 200513 (301 S PARK, 4TH FLOOR HELENA MT 59601 - Delivery) Helena, Montana 59620-0513 PHONE (406) 841-2356 FAX (406) 841-2344 E-MAIL: dlibsdpha@mt.gov WEBSITE: www.pharmacy.mt.gov Approval of Pharmacy Technician Utilization Plan LICENSE NUMBER PHARMACY NAME Address City State Zip Code State Zip Code PHYSICAL ADDRESS City TELEPHONE NUMBER FAX NUMBER ATTACH A COPY OF THE TECHNICIAN UTILIZATION PLAN SUPERVISING PHARMACIST(S) Name: MT License # Name: MT License # Name: MT License # Name: MT License # Name: MT License # PHARMACY TECHNICIAN(S) EMPLOYED IN THE PHARMACY Name: MT License # Name: MT License # Name: MT License # Name: MT License # Name: MT License # American LegalNet, Inc. www.FormsWorkFlow.com CERTIFIED PHARMACIES REVISED 05/07, 12/07, 9/08, 3/09, 7/09, 03/10, 08/10, 4/12 Page 11 of 11 I (we) do solemnly swear and affirm that I (we) have read and understood the Montana Pharmacy Technician Utilization Plan statutes and rules and that all statements made in this application for approval are true and correct in all respects. SIGNATURE(S) OF SUPERVISING PHARMACIST(S) You must submit any amendments to this plan to the Montana Board of Pharmacy office in writing within 10 days of the changes. DELCARATION I authorize the release of information concerning my education, training, record, character, license history and competence to practice, by anyone who might possess such information, to the Montana Board of Pharmacy. I hereby declare under penalty of perjury the information included in my application to be true and complete to the best of my knowledge. In signing this application, I am aware that a false statement or evasive answer to any question may lead to denial of my application or subsequent revocation of licensure on ethical grounds. I have read and will abide by the current licensure statutes and rules of the State of Montana governing the profession. I will abide by the current laws and rules that govern my practice. Signature:_________________________________________ Date:___________________ American LegalNet, Inc. www.FormsWorkFlow.com