INSTITUTIONAL CERTIFIED PHARMACY REVISED 10/17 Page 1 of 13 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: dlibsdpha@mt.gov 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 INSTITUTIONAL PHARMACIES 24.174.1101-1115 ARM: Prior to conducting business, a pharmacy must secure a license and be registered with the Board 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. 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 an institutional 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. 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** DOCUMENTS: The following documents must be submitted to the Board office in order to complete your 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 form Complete the Pharmacist-in-Charge Non-Owner Pharmacist Agreement form if applicable American LegalNet, Inc. www.FormsWorkFlow.com INSTITUTIONAL CERTIFIED PHARMACY REVISED 10/17 Page 2 of 13 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: The pharmacist-in-charge shall establish written policies and procedures for the safe and efficient distribution of drugs and provision of pharmaceutical care, including the mechanism by which drug review will be accomplished and documented. A current copy of such procedures must be on hand for inspection by the Board of Pharmacy. 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 dlibsdpha@mt.gov PLEASE BE SURE TO REVIEW THE MONTANA LAWS AND RULES ON THE WEBSITE American LegalNet, Inc. www.FormsWorkFlow.com INSTITUTIONAL CERTIFIED PHARMACY REVISED 10/17 Page 3 of 13 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: dlibsdpha@mt.gov WEBSITE: pharmacy.mt.gov Institutional Pharmacy 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. PLEASE CHECK THE TYPE OF OWNERSHIP OR OPERATION AND ATTACH THE REQUIRED INFORMATION Sole Proprietor Partnership Corporation Other 10. 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 11. Has this business or the pe rson 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 document ation from the source. Yes No American LegalNet, Inc. www.FormsWorkFlow.com INSTITUTIONAL CERTIFIED PHARMACY REVISED 10/17 Page 4 of 13 12. 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 13. Has the perso n 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 14. 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 supporti ng documentation from the source. Yes No 15. 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 16. 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