Pharmacy Community-Certified Form. This is a Montana form and can be use in Board Of Pharmacy Statewide.
Tags: Pharmacy Community-Certified, Montana Statewide, Board Of Pharmacy
Board of Pharmacy Community Pharmacy REVISED 10/17 Page 1 of 14 MONTANA BOARD OF PHARMACY (301 S PARK, 4TH FLOOR, HELENA, MT 59601- Delivery) P. O. Box 200513 Helena, Montana 59620-0513 (406) 841-2300 FAX (406) 841-2344 E-MAIL: firstname.lastname@example.org WEBSITE: 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 PHARMACY: 24.174.801-822 ARM: Prior to conducting business, a pharmacy must secure a license and be registered with the Board 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 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)444-1575 Telepharmacy 24.174.1302 ARM: o A remote telepharmacy site shall be connected to its parent pharmacy via computer, video and audio link. o A site cannot be licensed as a remote telepharmacy site if it is located within a twenty mile radius of an existing pharmacy. o The registered pharmacy technician present at the remote telepharmacy site must be currently registered with the Board, current certification with the Pharmacy Technician Certification Board (PTCB) or Exam for Certification of Pharmacy Technician (ExCPT) and have at least 500 hundred hours experience as a pharmacy technician, technician-in-training, or experience deemed as equivalent by the Board. FEES: $240 226 (Non-Refundable) - Application Fee $75 226 (Non-Refundable) - Dispense under the Montana Dangerous Drug Act $75 226 (Non-Refundable) 226 Pharmacy Technician Utilization Plan **Make check or money order payable to the Montana Board of Pharmacy** American LegalNet, Inc. www.FormsWorkFlow.com Board of Pharmacy Community Pharmacy REVISED 10/17 Page 2 of 14 DOCUMENTS: The following documents must be submitted to the Board office in order to complete the license application. Please make 8 275224 x 11224 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 Pharmacist-in-Charge Agreement form Complete the Pharmacist-in-Charge Agreement (Non-Pharmacist Owner) form if applicable APPLICATION PROCEDURES: When the application file is complete, it will be processed and considered by Board staff for permanent licensure. The applicant may 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, whole 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 al 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 pharmacy.mt.gov or email at email@example.com PLEASE BE SURE TO REVIEW THE MONTANA LAWS AND RULES ON THE WEBSITE American LegalNet, Inc. www.FormsWorkFlow.com Board of Pharmacy Community Pharmacy REVISED 10/17 Page 2 of 14 MONTANA BOARD OF PHARMACY (301 SOUTH PARK, 4TH FLOOR, HELENA, MT 59601- Delivery) P. O. Box 200513 Helena, Montana 59620-0513 (406) 841-2300 FAX (406) 841-2344 E-MAIL: firstname.lastname@example.org WEBSITE: pharmacy.mt.gov Community 1. NAME 2. MAILING ADDRESS Street or PO Box # City and State Zip 3. PHYSICAL ADDRESS City and State Zip EMAIL ADDRESS 4. TELEPHONE ( ) FAX ( ) 5. Tax ID NUMBER 6. PHARMACIST-IN-CHARGE MT LICENSE # Address City: State: Zip Code Phone Fax 7. 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. Will Home Infusion Therapy be provided? Yes No If, yes, proof of licensure the Montana Department of Health and Human Services (DPHHS) is required 10. Is this a telepharmacy? Yes No American LegalNet, Inc. www.FormsWorkFlow.com Board of Pharmacy Community Pharmacy REVISED 10/17 Page 3 of 14 11. PLEASE CHECK THE TYPE OF OWNERSHIP OR OPERATION AND ATTACH THE REQUIRED INFORMATION Sole Proprietor Partnership Corporation Other 12 . 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 13 . 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 14 . Has the person in charge of this business who is listed on this app lication 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 do