Free 50248.FH11 - Indiana

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APPLICATION FOR REGISTRATION AS A NON-RESIDENT PHARMACY IN THE STATE OF INDIANA
State Form 50248 (R3 / 1-09) Approved by State Board of Accounts, 2009

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

FOR OFFICE USE ONLY
Application fee Date of issuance (month, day, year) Date fee paid (month, day, year) Registration number Receipt number Case manager

DO NOT WRITE ABOVE THIS LINE

APPLICANT INFORMATION
Type of application (please check appropriate box):

New facility
Name of pharmacy

Change of ownership (provide current Indiana license number)

Change of location (provide current Indiana license number)
Current Indiana license number

Address of pharmacy (number and street, city, state, and ZIP code) Toll-free telephone number (accessible by Indiana patients) Local telephone number

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)

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Name of pharmacist-in-charge E-mail address

State Web site address

License number

NCPDP number (If you currently do not have a NCPDP number, you will need to provide that immediately upon receipt.) If change of ownership, previous name If change of location, previous address (number and street, city, state, and ZIP code) Approximate percentage of total prescription volume received or solicited online Approximate number of Indiana residents to be served Verified Internet Pharmacy Practice Site (VIPPS) accredited?

Yes

No

The days of the week and hours that a pharmacist is available to speak to Indiana patients via toll free line (IC 25-26-17-4 requires at least forty (40) hours and six (6) days a week; if on-call to meet this requirement, please explain on-call procedure)

When a pharmacist is answering questions from Indiana patients via the toll-free line, does the pharmacist have immediate access to the records and the drug profile of the patient?

If no, please explain.

Yes

No

If your answer is yes to any of the following, explain fully in a signed and notarized statement, including all related details and documentation. Include the violation, location, date, and disposition. Falsification of any of the following is grounds for permanent revocation of a registration issued pursuant to this application. 1. Has your facility or any of your pharmacists or technicians been convicted of, or pled guilty to, a violation of a federal or state law or are criminal charges pending? 2. Have any of your pharmacist or pharmacy technician licenses been disciplined or are formal charges pending? 3. Has your facilitys license(s) been disciplined or are formal charges pending in your state of domicile or any other state in which the facility is licensed? 4. Has your facility been denied a license or registration in any state? 5. Have you had any action, discipline, or revocation on any federal registration you hold or have held? Yes Yes Yes Yes Yes No No No No No

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DELIVERY SERVICES Delivery Service(s) Utilized Percentage of Time Utilized

Are there any special packaging or shipping procedures used to assure proper shipping conditions for the medications being shipped to Indiana residents? Please explain.

When medications are delivered to Indiana residents, are there any special delivery policies in place? (Check all that apply.)

Medications must be signed for by ___________________________________ Medications may be left with a non-adult person at the household. Medications may be left at the house when no one is at home. Medications do not have to be signed for. Other. Please explain your policy: ____________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ ADDITIONAL REQUIRED INFORMATION The following items must be submitted to complete this application: 1. A $100 application fee. 2. A list of the name, titles, and cities of residence of all corporate officers and staff pharmacists, including the pharmacists license numbers. 3. Verification of current license or certification of the pharmacy and all listed pharmacists, verified by your home state board of pharmacy. 4. A sample label that will be used on the medication containers of Indiana residents; label must include the toll free number for Indiana patients to call. 5. A copy of the last Board inspection report by your home state board. 6. A copy of your VIPPS accreditation from National Association of Boards of Pharmacy (NABP); this is required if your total prescription volume received or solicited online is more the 25%. APPLICATION AFFIRMATION I hereby swear or affirm under penalties or perjury that the statements made in this application are true, complete, and correct.
Signature of pharmacist-in-charge Signature of owner / officer Printed name of owner / officer Title Date (month, day, year) Date (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency, or the Indiana Board of Pharmacy, any files, documents, records or other information pertaining to the undersigned requested by the Agency, or the Board, or any of their authorized representatives in connection with processing my application for licensure. I hereby release the aforementioned persons, firms, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency, or the Indiana Board of Pharmacy, to disclose to the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions any information which is material to my application, and I hereby specifically release the Agency, and the Board from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original. AFFIRMATION I hereby swear or affirm, that I have read the above statements and agree to same.
Signature of owner / officer Date signed (month, day, year)

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