Montana > Statewide > Board Of Pharmacy
Mail Order Pharmacy - Montana
| Mail Order Pharmacy Form. This is a Montana form and can be used in Board Of Pharmacy Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Board of Pharmacy Mail Order Pharmacy REVISED 05/07, 12/07, 3/09, 7/09,01/10, 02/10, 03/10, 6/10, 08/10, 5/11, 8/11, 4/12, 6/12 Page 1 of 12 MONTANA BOARD OF PHARMACY P. O. Box 200513 (301 S PARK, 4TH FLOOR HELENA MT 59601 - Delivery) Helena, Montana 59620-0513 PHONE (406) 841-2355 or 2356 FAX (406) 841-2344 E-MAIL: dlibsdpha@mt.gov WEBSITE: www.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 REGISTRATION REGISTRATION REQUIREMENTS Be a legal entity registered and in good standing with the Montana Secretary of State. Information available at www.sos.mt.gov Registered and in good standing with the National Association of Board of of Pharmacy Verified Internet Pharmacy Practice Sites (VIPPS) if registered after June 2, 2001, and if services provided online. Maintain, in readily retrievable form, records of legend drugs and/or devices dispensed to Montana patients Supply upon request, all information needed by the Montana Board of Pharmacy to carry out the Board's responsibilities under the statutes and regulations pertaining to out-of-state mail service pharmacies Maintain pharmacy hours that permit the timely dispensing of drugs to Montana patients and provide reasonable access for the Montana patients to consult with a licensed pharmacist about such patients' medications Provide toll-free telephone communication consultation between a Montana patient and a pharmacist at the pharmacy who has access to the patient's records, and ensure that said telephone number(s) will be placed upon the label affixed to each legend drug container. Toll-free telephone service must be available at least 6 days a week and for 40 hours a week. A toll-free telephone number shall also be provided to the Board to allow for compliance with all information requests by the Board. Identify a pharmacist in charge of dispensing prescriptions for shipment to Montana Each pharmacy that provides home infusion therapy services to Montana must be licensed with both the Board of pharmacy and the Department of Public Health and Human Services (DPHHS). Information about licensing with DPHHS can be obtained at www.dphhs.mt.gov or by calling (406) 444-1742 FEES $400.00 (Non-Refundable) - Application Fee $ 75.00 (Non-Refundable) - Montana Dangerous Drug Act Dispenser Fee **Make check or money order payable to the Montana Board of Pharmacy** The following documents must be submitted to the Board office in order to complete your license application. Please make 8-1/2"x11" copies of the following and submit with your application. Attach a copy of your current DEA registration if applying for Dangerous Drug Dispenser Registration Copy of last State Inspection Proof of registration with Montana Secretary of State. Go to "Business Services" then to "Forms" then "Business Forms" click on type of ownership or operation "Foreign" (as this business is foreign to the State of Montana) then to "Certificate of Authority". Proof of licensure with the Montana DPHHS if providing home infusion therapy services Copy of a Technician Utilization Plan DOCUMENTS American LegalNet, Inc. www.FormsWorkFlow.com Board of Pharmacy Mail Order Pharmacy REVISED 05/07, 12/07, 3/09, 7/09, 01/10, 02/10, 03/10, 6/10, 08/10, 4/12, 6/12 Page 2 of 12 ADDITIONAL FORMS TO BE SUBMITTED FOR AN APPLICATION TO BE COMPLETE National Practitioner Data Bank (NPDB) self-query. This form can be obtained by calling NPDB at 800-767-6732 or visit www.npdb-hipdb.hrsa.gov on the Internet. This form must be mailed directly to the address indicated in the instructions. The results will come to you; upon receipt please forward them to the Board office. Go to "Perform a Self-Query" and to "Perform a Self-Query on an Organization". Verification of licensure in good standing in the state in which the business is located Verification of licensure in good standing of the Registered Pharmacist-in-Charge If the pharmacy provides home infusion therapy services to Montana verification of licensure in good standing with the Department of Health and Human Services (DPHHS). Information about licensing with DPHHS can be obtained at www.dphhs.mt.gov or by calling (406) 444-1742 APPLICATION PROCEDURES When the application file is complete, it will be processed and considered by Board staff for permanent registration. The applicant will be notified is 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. Verification of licensure must be sent directly to the state board in which the business is located or the pharmacist-in-charge is employed. Please contact the state board prior to sending the request as some states may charge a fee for verification. 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 an approved a permanent registration will be issued. ADDITIONAL LAW and RULE INFORMATION Pharmacist-in-Charge Be licensed in good standing in the state in which the out-of-state mail service pharmacy is located Be properly listed on the application form prescribed by the Board Comply with all applicable Montana laws and rules Notify the Montana Board promptly of any relevant changes in employment or address, etc. Notify the Montana Board promptly of any disciplinary actions initiated and/or finalized against the pharmacist's license Agent of Record Any such out-of-state mail service pharmacy that does not so designate a resident agent and that ships, mails or delivers prescription drugs and/or devices in the state of M
|
|||||||
