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 NON-RESIDENT PRESCRIPTION DRUG OUTLET (OSP) New Pharmacy or Transfer Ownership: $450 Change Location: $125 Change Name or Change Manager: $35 Fees may be paid by a check or money order drawn in U.S. dollars on a U.S. bank and made payable to State of Colorado
THIS APPLICATION MAY ONLY BE USED FOR THE PURPOSES OF: 1.
REGISTERING ENTITIES LOCATED WITHIN THE UNITED STATES; AND
2.
EXCEPT AS ALLOWED PURSUANT TO BOARD RULE 21.00.20, DISPENSING/DELIVERING PRESCRIPTIONS INTO COLORADO PURSUANT ONLY TO VALID, PATIENT-SPECIFIC PRESCRIPTION ORDERS. IT MAY NOT BE USED FOR THE PURPOSE OF DISTRIBUTING DRUGS (COMPOUNDED OR OTHERWISE) INTO COLORADO. (This application must also be used for changes to existing registrations) APPLICANT INSTRUCTIONS
Basic Requirements. Requirements for registration are outlined in Section 12-42.5-130 of the Colorado Revised Statutes (C.R.S.) and the Board rules. Both can be found online at: www.dora.colorado.gov/professions/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. 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 non-resident prescription drug 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.
11/2016
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 NON-RESIDENT PRESCRIPTION DRUG OUTLET (OSP) New Pharmacy or Transfer Ownership: $450 Change Location: $125 Change Name or Change Manager: $35 Fees may be paid by a check or money order drawn in U.S. dollars on a U.S. bank and made payable to State of Colorado
APPLICANT CHECKLIST For a NEW REGISTRATION or to TRANSFER OWNERSHIP of a current 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 on a U.S. bank and made payable to State of Colorado. All fees are non-refundable and subject to change every July 1. Attach verification of the current pharmacy license issued by the state of residence. You may submit the detailed online screen print from the state Board of Pharmacy webpage. The screen print must list the facility address and must address any discipline, if applicable. Include a copy of the most recent report of inspection of the non-resident pharmacy by either its resident state board of pharmacy or the National Association of Boards of Pharmacy Verified Pharmacy Program dated within two (2) years of submission of this application. If you will be distributing into Colorado a compounded drug to a Colorado-licensed veterinarian for office stock, you must submit: i)
ii)
A National Association of Boards of Pharmacy Verified Pharmacy Program inspection report detailing an inspection of the outlet conducted within the last year. The Board must approve the inspection report as satisfactorily demonstrating proof of compliance with the Board’s own inspection procedures and standards prior to distributing compounded products to Colorado-licensed veterinarians; and A copy of a currently valid Drug Enforcement Administration manufacturer registration for the outlet.
To CHANGE the LOCATION, PHARMACY NAME or PHARMACIST MANAGER of an existing registration: DO NOT use this form to change the location of your facility to a new state. If your facility wishes to continue shipping prescriptions into Colorado, you must apply for and receive a new Registration. Complete a Notification of Closure form available at www.dora.colorado.gov/professions/pharmacy for the current 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 on a U.S. bank and made payable to State of Colorado. All fees are non-refundable and subject to change every July 1. Attach verification of the current pharmacy license issued by the state of residence. You may submit the detailed online screen print from the state Board of Pharmacy webpage. The screen print must list the facility address and must address any discipline, if applicable. All required items must be submitted to the Office of Licensing in ONE COMPLETE PACKAGE. Incomplete applications will delay processing time. Return your completed application packet and all supporting documentation to: Division of Professions and Occupations Office of Licensing—Pharmacy 1560 Broadway, Suite 1350 Denver, CO80202
Applicant: Keep this page for your records.
11/2016
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 NON-RESIDENT PRESCRIPTION DRUG OUTLET (OSP) New Pharmacy or Transfer Ownership: $450 Change Location: $125 Change Name or Change Manager: $35 Fees may be paid by a check or money order drawn in U.S. dollars on a U.S. bank and made payable to State of Colorado
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 pharmacy registration. I may distribute into Colorado a compounded drug to a Colorado-licensed veterinarian for office stock 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: New owner name: Effective date of new ownership: I am reporting a change in existing registration as follows: (select all that apply) Change of Location Previous location: Effective date of new location: Change of Pharmacy Name Previous pharmacy name: Effective date of new name: Change of Pharmacist Manager Previous Pharmacist Manager: License Number: State: Last date employed as Pharmacist Manager:
$450
$450
$125
$35
$35
Total Fee:
$
PART 2. 1.
Pharmacy Name:
2.
Colorado Registration Number:
3.
Pharmacy Business License Number – State of Residence:
4.
Federal Employer Identification Number (FEIN):
5.
Facility Business Address:
If this is a new registration, leave blank.
Street & Number 6.
Daytime Telephone:
7.
E-mail Address:
8.
Pharmacist Manager:
State
Zip Code
Fax:
License Number: OFFICE USE ONLY
City
State:
Date Managership Began:
REGISTRATION NUMBER: ________________________
Non-Resident Prescription Drug Outlet
Page 1 of 3
DATE ISSUED: ______________________________ 11/2016
9. Is this pharmacy certified by NABP’s Verified Internet Pharmacy Practice Sites (VIPPS) program?
• • •
YES
NO
IMPORTANT You MUST file for a Transfer of Ownership: If the prescription drug outlet is owned by a corporation, upon the sale or transfer of 20% or more of the shares to a single individual or entity. Upon the sale or transfer of any ownership interest of 20% or more to a single individual or entity. Upon the incorporation of an existing Prescription Drug Outlet.
10. Indicate the type of ownership and enter the required information: (attach additional pages if necessary) Individual, trustee, or receiver Name: Partnership Name: Corporation Name: State where incorporated: Date of last biennial report (if required by state where incorporated: Corporate officers (attach additional pages if necessary): Name
Title
Social Security Number
PART 3. 11. 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?
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 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 suspended or revoked?
YES
NO
Non-Resident Prescription Drug Outlet
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ATTESTATION The undersigned hereby states: • • • • •
that all information contained in this application for a nonresident pharmacy registration is true and correct; that he/she has read and is familiar with all the provisions of the law relative to the conduct of a Non-resident PDO in Colorado; that such provisions of the law will be faithfully observed; that the nonresident pharmacy complies with C.R.S. 12-42.5-130(1)(b); and that the nonresident pharmacy will dispense/deliver prescription drugs or controlled substances into Colorado pursuant ONLY to valid, patient-specific prescription orders, except as provided pursuant to Board Rule 21.00.20
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.
Pharmacist Manager’s Signature
Non-Resident Prescription Drug Outlet
Date
Page 3 of 3
11/2016
