Division of Professions and Occupations Office of Licensing—Pharmacy 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7800 / Fax (303) 894-7693 www.dora.colorado.gov/professions
Application for Registration OTHER OUTLET New Registration: $150 / Transfer Ownership: $100 Change Name: $35 / Change Location: $125 Change Consultant Pharmacist: No Fee
(This application must also be used for changes to existing registrations.) APPLICANT INSTRUCTIONS Basic Requirements. Requirements for registration are outlined in the Section 12-42.5-112 of the Colorado Revised Statutes, (C.R.S.) and the Board rules. Both can be found online at: www.dora.colorado.gov/professions/pharmacy.
An Other Outlet is a non-pharmacy outlet from which prescription drugs and/or controlled substances are dispensed to patients of the outlet. The following types of facilities may qualify for registration: • Family planning clinic • Jails • Ambulatory surgery center • County or district public health agency • Medical clinic operated by a hospital • Community and rural health clinics • Inpatient Hospice (including Federally Qualified Health Centers) • Acute Treatment Unit • School, college or university • Telepharmacy student/faculty health services • Hospitals, not currently operating a prescription drug outlet (pharmacy)
About the Application. This application is to be completed by you and returned to the Office of Licensing. All questions on the application are mandatory, and all supporting documents must be submitted with the application. You may copy as many forms as needed; however, each form submitted must be completed in original ink or typed. Be sure to keep a copy of the completed application for your records. Application Expiration. Your application will be kept on file for one (1) year from date of receipt in the Division. Your file and all supporting documentation will be purged if you do not submit required documents and complete your application process in one year. You will need to resubmit a new application packet and fee after that time. Disclosure of Addresses. Consistent with Colorado law, all addresses and phone numbers on record with the Division are public record and must be provided to the public when requested. It is your responsibility to keep your contact information current in our system. Your email address is not open to public record, but must be provided in this application. Any requests for additional information, license information and renewal notices will be emailed to the email address on record. If your email address is not current, it is possible you will not receive important information from the Division. You can change your contact information online by using Online Services at: www.dora.colorado.gov/professions/onlineservices. Checking Your Application Status. Visit Online Services at: www.dora.colorado.gov/professions/onlineservices to track your application from the date we log it in our database to the date your license is available for printing. Please allow us enough time to receive the application through the mail and enter your application into our database before you check the website. We recommend waiting at least 10 business days from date of mailing before checking the status of your application. Registration Expiration Grace Period for New Applicants. All new applicants who are issued a registration within 120 days of the upcoming renewal expiration date will be issued a registration with the subsequent expiration date. For example, registrations issued between July 4, 2016 and October 31, 2016 will reflect an expiration date of October 31, 2018. Registrations issued prior to July 4, 2016 will reflect an expiration date of October 31, 2016 and must renew in the upcoming renewal period.
All other outlet registrations expire on October 31 of even-numbered years and must be renewed to continue practicing.
Printing your Registration upon Approval. DORA is no longer printing and mailing wallet cards as registrations. To print your wallet card registration in its current status, login to your Online Services account at: www.dora.colorado.gov/professions/onlineservices and select “Print Your License” in the left-hand menu.
Applicant: Keep this page for your records.
6/2010
Division of Professions and Occupations Office of Licensing—Pharmacy 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7800 / Fax (303) 894-7693 www.dora.colorado.gov/professions
Application for Registration OTHER OUTLET New Registration: $150 / Transfer Ownership: $100 Change Name: $35 / Change Location: $125 Change Consultant Pharmacist: No Fee APPLICANT CHECKLIST
For new Other Outlet registration, to transfer ownership of a current Other Outlet registration, or to change the business name or location: Submit a completed application and supporting documentation if required. Return the completed application and all supporting documentation to the Office of Licensing. Enclose the non-refundable application-processing fee. Fees may be paid by check or money order drawn in U.S. dollars and made payable to State of Colorado. All fees are non-refundable and subject to change every July 1. Attach two (2) copies of completed Other Outlet Protocol Form. All applicable supplements referenced in the completed form must also be submitted.
The protocols must be typed on forms supplied by the Board. A Microsoft Word fill-in form is available on our website at www.dora.colorado.gov/professions/pharmacy.
Two copies of all protocols and supplements are required for application processing. If two copies are not submitted, the facility will be charged a copy fee of $0.25 per page. This fee must be paid prior to approval.
To change the consultant pharmacist of a current Other Outlet registration: Submit a completed application and supporting documentation if required. Return the completed application and all supporting documentation to the Office of Licensing. Enclose the non-refundable application-processing fee. Fees may be paid by check or money order drawn in U.S. dollars and made payable to State of Colorado. All fees are non-refundable and subject to change every July 1. For protocol changes: All protocol changes must be submitted to and approved by the Board prior to implementation. Submit two (2) copies of completed Other Outlet Protocol Form. All applicable supplements referenced in the completed form must also be submitted.
The protocols must be typed on forms supplied by the Board. A Microsoft Word fill-in form is available on our website at: www.dora.colorado.gov/professions/pharmacy.
Two copies of all protocols and supplements are required for application processing. If two copies are not submitted, the facility will be charged a copy fee of $0.25 per page. This fee must be paid prior to approval. Return your completed application packet and all supporting documentation to: Division of Professions and Occupations Office of Licensing—Pharmacy 1560 Broadway, Suite 1350 Denver, CO 80202
Applicant: Keep this page for your records.
6/2010
Division of Professions and Occupations Office of Licensing—Pharmacy 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7800 / Fax (303) 894-7693 www.dora.colorado.gov/professions
Application for Registration OTHER OUTLET New Registration: $150 / Transfer Ownership: $100 Change Name: $35 / Change Location: $125 Change Consultant Pharmacist: No Fee
The content of this application must not be changed. If the content is changed, the applicant may be referred to the Colorado State Attorney General’s Office for violation of Colorado law. If additional pages are attached to respond to requested information in any part of the application, please indicate the number of the item to which you are responding. PART 1. Select from the following and submit the appropriate fee for each selection: I am submitting an application for new Other Outlet registration. Enclose fee with your application and continue to Part 2. —OR— I am reporting a Transfer of Ownership for a current registration. Previous owner name: Effective date of new ownership: I am reporting a change in existing registration as follows: (select all that apply) Change of Business Location Previous location: Effective date of location change: Change of Business Name Previous business name: Effective date of new name: Change of Consultant Pharmacist Previous consultant pharmacist: Effective date of change: Total Fee:
$150
$100
$125
$35
No fee
$
PART 2. 1. Colorado Registration Number:
If this is a new registration, leave blank.
2. Business Name: List all trade names or DBA names used by business:
3. Federal Employer Identification Number (FEIN): 4. Mailing Address: Street & Number
City
State
Zip Code
City
State
Zip Code
5. Physical Address (if different): Street & Number
Other Outlet
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06/2015
Division of Professions and Occupations Office of Licensing—Pharmacy 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7800 / Fax (303) 894-7693 www.dora.colorado.gov/professions
6. Daytime Telephone:
Application for Registration OTHER OUTLET New Registration: $150 / Transfer Ownership: $100 Change Name: $35 / Change Location: $125 Change Consultant Pharmacist: No Fee Fax Number:
7. E-mail Address: 8. Type of Organization(if your facility does not fall into one of these categories, you are not eligible for registration as an Other Outlet): Acute Treatment Unit Jail Medical clinic operated by a hospital County or district health department Community or rural health clinic (Including Federally Qualified Health Centers)
Telepharmacy School, college or university student/faculty health service Hospice with inpatients Hospital, not currently operating a prescription drug outlet Family planning clinic Ambulatory surgery center
9. Type of Ownership (check one and complete information as applicable): Individual, Trustee, or Receiver Full name of Owner/Trustee/Receiver: Individual’s Social Security Number: Partnership Name of Partnership: Federal Employer Identification Number: List full name and Social Security Number of each partner (attach additional pages if necessary):
Corporation ATTACH A STATEMENT to this application listing the following: Name, Social Security Number, and title of each corporate officer and director Name of parent company, if any Corporate names and state of incorporation Federal Employer Identification Number of the business entity Date of last annual report to Colorado Governmental Entity Name of Director: Name of Governmental Entity: 10. Operational Information: Days and Hours of operation of the facility: Days and Hours when a responsible person with access to the drugs and records is on-site to permit the Board of Pharmacy to inspect the facility and drugs and review appropriate records: Name and title of contact person at the facility: 11. Consultant Pharmacist: This is the person responsible for providing written, board-approved protocols for dispensing by non-pharmacists. The Consultant Pharmacist must also perform inspections of the Other Outlet to assure compliance with the protocols, as well as any other duties explained in the Board’s rules. Name: Place of practice (name): Other Outlet
Colorado License Number: Page 2 of 3
06/2015
Division of Professions and Occupations Office of Licensing—Pharmacy 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7800 / Fax (303) 894-7693 www.dora.colorado.gov/professions
Application for Registration OTHER OUTLET New Registration: $150 / Transfer Ownership: $100 Change Name: $35 / Change Location: $125 Change Consultant Pharmacist: No Fee
Business address: Home address: Telephone numbers (with area code): Work:
Home:
Signature of Consultant Pharmacist:
Date: PART 3.
12. Background Questions: If the answer to any question is YES, attach additional pages and explain fully. A. Has the applicant or any person identified in this application been convicted under any federal, state, or local law relating to drug samples, drug manufacturing, drug dispensing, wholesale or retail drug distribution, or distribution of controlled substances?
YES
NO
B. Has the applicant or any person identified in this application had any criminal or civil conviction under federal or state laws? (This includes deferred judgments or sentences.)
YES
NO
C. Has any person identified in this application had any license or registration to manufacture, dispense, or distribute legend drugs or controlled substances disciplined, suspended or revoked?
YES
NO
D. Has any person identified in this application been convicted of a felony or pled nolo contendere to a felony under any federal, state, or local law?
YES
NO
E. Has any registration or license to manufacture or distribute legend drugs and/or controlled substances currently or previously held by applicant ever been disciplined, suspended or revoked?
YES
NO
Per § 12-4-104(13)(a), C.R.S., any applicant who, under oath, supplies false information to an agency in an application for a license, commits perjury in the second degree as defined in § 18-8-503, C.R.S. In accordance with §§ 18-8-503 and 18-8-501(2)(a)(l), C.R.S., false statements made herein are punishable by law.
THIS APPLICATION COMPLETED BY: Signature: Name:
Other Outlet
Date: Title:
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