Free 30410.FH11 - Indiana

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APPLICATION FOR PERMIT TO OPERATE, MAINTAIN, OPEN, OR ESTABLISH A PHARMACY IN THE STATE OF INDIANA
State Form 30410 (R6 / 2-06) Approved by State Board of Accounts, 2006

INSTRUCTIONS: Submit a drawing or blueprint showing the physical size (list linear dimensions) and general layout of the floor plan. In specific, show the location of the prescription counter top and give the linear dimensions, show the location of the refrigerator, and prescription sink. The completed application should be in this office no later than 7 days prior to the scheduled Board meeting and should be filed at least 30 days prior to the anticipated date of opening or change of location. Change of ownership applications shall be filed within ten (10) days of the acquisition. You must secure the federal application from the DEA office. Fill out and mail the DEA application indicating that your Indiana Controlled Substance Registration is pending. Mail the federal form to the DEA when you mail your application to this office. The DEA application may take up to 12 weeks to process. It is your responsibility to notify the DEA of the change of location. In case of change of locations, neither the permit or CSR numbers will change. FOR AGENCY USE ONLY
Date of Board approval (month, day, year) Identification number Application fee CSR number Date of inspection (month, day, year) Permit number Inspection by Receipt Date of issuance (month, day, year) Case manager

INDIANA BOARD OF PHARMACY PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2067 E-mail: [email protected] www.pla.IN.gov

Date fee paid (month, day, year)

DO NOT WRITE ABOVE THIS LINE
APPLICATION FEE / INFORMATION Please check appropriate box below and send proper fee as noted on enclosed instructions.
New store Title or trade name If change of owner, previous trade name Location of pharmacy (number and street, city) If change of location, old location if different street address (number and street, city) NCPDP number County Change of ownership Change of location / remodel Fee exempt (for CSR only) State CSR Current pharmacy license number Application is enclosed County or state ownership Name of qualifying pharmacist (must be removed from old store prior to store opening) License number of qualifying pharmacist ZIP code Telephone number

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If you do not have a number, please provide to the Board of Pharmacy upon receipt. PHYSICAL INFORMATION
Room dimensions Wareroom Basement 2nd floor

Rx counter top dimensions

Are there any interior doors leading to space not included above? (if yes, explain) Proposed date of opening, relocation, or acquisition (month, day, year) A favorable inspection report by a Board's inspector is required before operations in a new store or a new location may commence. Inspections are made only after pharmacy is stocked as permitted by law; give Board ample notice.

OWNERSHIP TYPE Check the appropriate box below and provide requested information for owners and agents.
A. INDIVIDUAL - If pharmacist,list name followed by Indiana license number and home address. B. INDIVIDUAL - If non-pharmacist, list name and home address. C. PARTNERSHIP - List names of all partners, Indiana license number if pharmacist, and home address. D. CORPORATION - Give name of corporation, followed by names and home addresses of all officers. Indiana license number following if pharmacists. E. ESTATE - Name of executor and attach certified copy of order of appointment. F. STATE OWNERSHIP - List names of trustees or appointed official in charge. G. COUNTY OWNERSHIP - List names of trustees or appointed official in charge. Name Home address (number and street, city, state, and ZIP code)

PERMIT CLASSIFICATION Check the appropriate box and fill in appropriate data. TYPE I. A retail permit for a pharmacy that provides pharmaceutical care to the general public by the dispensing of a drug or device. TYPE II. An institutional permit for hospitals, clinics, health care facilities, sanitariums, nursing homes, or dispensaries that offer pharmaceutical care by dispensing a drug product to an inpatient under a drug order or to an outpatient of the institution under a prescription. TYPE III. A permit for a pharmacy that is NOT: (A) open to the general public; or (B) located in an institution listed under TYPE II permit; and provides pharmaceutical care to a patient who is located in an institution or in the patient's home. TYPE IV. A permit for a pharmacy not open to the general public that provides pharmaceutical care by dispensing drugs and devices to patients exclusively through the United States Postal Service or other parcel delivery services. TYPE V. A permit for a pharmacy that engages exclusively in the preparation and dispensing of diagnostic or therapeutic radioactive drugs. TYPE VI. A permit for a pharmacy open to the general public that provides pharmaceutical care by engaging in an activity under a TYPE I or TYPE III permit. A pharmacy that obtains a TYPE VI permit may provide services to: (A) a home health care patient; (B) a long term care facility; or (C) a member of the general public. SCHEDULE OF LICENSED PHARMACISTS IN ATTENDANCE AT PHARMACY Each pharmacist must personally sign, and legibly print their name, list license number, and hours worked here and elsewhere. Every pharmacy shall have a manager who shall be a pharmacist licensed under the laws of Indiana. If change of manager during term of permit, change of manager form must be filed. A pharmacist may qualify only one pharmacy permit.
Signature of manager (qualifying pharmacist) Signature(s) of other pharmacist(s) License number Weekly hours If employed elsewhere, state place / hours worked.

Number of beds

SCHEDULE OF HOURS OPEN FOR BUSINESS
Monday A.M. to Tuesday A.M. to P.M. P.M. Thursday A.M. to P.M. Wednesday A.M. to P.M. Saturday A.M. to P.M. Friday A.M. to P.M. Total weekly hours Sunday A.M. to P.M.

RULE 6.1. DRUGSTORES, PHARMACIES, APOTHECARY SHOPS

856 IAC 1-6.1-1 Pharmacy equipment; lack of access between adjacent pharmacies Authority: IC 25-26-13-4 Affected: IC 25-26-13-18 Sec. 1 (a) In addition to the requirements of IC 25-26-13-18, the qualifying pharmacist for each pharmacy issued a permit by the board shall be responsible for all decisions concerning the additional fixtures, facilities, and equipment needed by the pharmacy to operate properly in compliance with the law regulating pharmacies. In making those decisions, the qualifying pharmacist shall consider minimum health, safety, and security measures as well as the type and scope of practice, the patients needs, and the laws and rules that apply. (b) If requested by a representative of the Indiana board of pharmacy (board), the qualifying pharmacist shall justify, in writing, all decisions made under this rule. (c) The board shall determine whether minimum health, safety, and security measures have been satisfactorily met by an applicant for a pharmacy permit before the permit is issued or at any time the permit is in effect. (d) If the board determines that a pharmacy does not meet the requirements of IC 25-26-13-18 and this rule, it will identify and notify the qualifying pharmacist of the deficiencies. The qualifying pharmacist shall correct or cause to be corrected the deficiencies identified within thirty (30) days of notification by the board of the noncompliance. (e) Failure to timely correct the deficiencies identified is grounds for denial or revocation of a permit. (f) To assure that no pharmacy is left unattended by a pharmacist while that pharmacy is in operation, no means of access may be constructed or maintained between adjacent pharmacies. (Indiana Board of Pharmacy; 856 IAC 1-6.1-1; filed June 20, 2001, 3:59 p.m.: 24 IR 3651)

INVENTORY VALUATION Expressed as percentages of total value in licensed area. Legend drugs % Other items % Total %

ABSENCE OF PHARMACIST Do you intend to utilize the "Absence of Pharmacist" privilege under IC 25-26-13-19? Yes No A pharmacy holding a TYPE I or TYPE II permit may be open to the general public without a pharmacist on duty, if permission is obtained from the Board. A register showing the time the pharmacy is opened and closed must be maintained. All merchandise that can only be dispensed by a pharmacist must be secured when the pharmacist is absent and only the pharmacist may have access to that merchandise. During the pharmacist's absence, a sign at least 20 by 30 inches shall be prominently displayed in the prescription department stating "Prescription Department Closed, No Pharmacist on Duty". You will be sent an application for this privilege, if you check "Yes". INQUIRY OF LAW VIOLATIONS Has the applicant, any of the agents or listed pharmacists ever been convicted of, or plead guilty or nolo contendre to: A. A violation of any federal, state or local laws relating to the use, manufacturing, distributing, or dispensing of controlled substances or of drug addiction? Yes B. No

Any offense, misdemeanor, or felony in any state? (EXCEPT for violation of traffic laws resulting in fines.) Yes No If Yes to A or B, submit a sworn statement giving full details, include the violation location, date and disposition.

I hereby swear or affirm under the penalties of perjury that the above statements are true, complete and correct.
Signature of owner or agent Signature of manager (RPH) in charge of store

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Name of person to contact with questions concerning this application

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Telephone number

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Email address

SALE AGREEMENT Requirements: To be completed by owner selling a pharmacy. If incorporated, or more than one owner, President or executive officer in charge as listed with the Board must complete the sale agreement section. This is to certify and constitute an agreement of sale of the pharmacy at the location listed on this application.
Signature of seller

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Printed name of seller

Date effective (month, day, year)

PHARMACY REQUIREMENTS At the minimum, a pharmacy must: 1. be stationary; 2. have a complete enclosure extending from floor to ceiling level enclosing all the products offered for sale under the pharmacy permit; 3. have entry doors capable of being securely locked to prevent entry during those times when the pharmacy is closed; 4. be well lighted and ventilated with clean and sanitary surroundings; 5. be equipped with a sink with hot and cold running water or some means of heating water, a proper sewage outlet, and refrigeration; 6. have a prescription compounding counter providing a minimum of sixteen square feet of unobstructed area or twenty-four square feet, if two or more pharmacists are on duty at the same time, and the floor area extending the full length of the prescription compounding counter shall be clear and unobstructed for a minimum of thirty inches from the counter edge; 7. have such additional fixtures, facilities and equipment as the Board requires to enable it to operate properly as a pharmacy in compliance with federal and state laws and regulations governing pharmacies; 8. the wholesale value of the drug inventory on the licensed items must be at least 10% of the wholesale value of the items in the licensed area; and 9. other minimum requirements are as specified herein.