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Requirements For Filing A Clinic Permit Application 17M-28 - California
| Requirements For Filing A Clinic Permit Application Form. This is a California form and can be used in Board Of Pharmacy Statewide . |
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California State Board of Pharmacy 1625 North Market Blvd., Suite N219, Sacramento, CA 95834 Phone (916) 574-7900 Fax (916) 574-8618 www.pharmacy.ca.gov STATE AND CONSUMER SERVICES AGENCY DEPARTMENT OF CONSUMER AFFAIRS GOVERNOR EDMUND G. BROWN JR. REQUIREMENTS FOR FILING A CLINIC PERMIT APPLICATION IMPORTANT: Please follow these instructions completely. Failure to submit the necessary items will delay the processing of your application. If the number of forms provided is not sufficient, please make photocopies. You will be notified of any major deficiencies in your application. Please allow approximately 60 days from the time your application packet is complete before calling the Board of Pharmacy. Any forms that have been previously submitted with another application will not be pulled from the file. You must complete and submit all of the requested information. If you would like notification that the board has received your application, please submit a stamped postcard addressed to yourself. SUMMARY OF CHECKLIST Section A Section B Section C Section D Section E Section F Section G Section H Section I Requirements for all applicants except government owned, Indian tribe owned, or change of location. Forms required for an applicant who is filing as an individual owner Forms required for an applicant whose ownership is a partnership Forms required for an applicant who is filing as a corporation Forms required for an applicant who is filing as a limited liability company Requirements for state, city or county owned clinic Requirements for Indian tribe owned clinic Requirements for non-Indian owned but operating on tribal lands Requirements for change of location only (no ownership change) Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com CHECKLIST FOR FILING A CLINIC PERMIT APPLICATION Section A [] [] [] [] [] All Applicants 1. Application (17A-42) and the non-refundable processing fee of $400. 2. A copy of your Department of Health Services license or a statement on company letterhead citing the Health and Safety Code exception. 3. On company letterhead written certification that policies and procedures are in place. 4. If Medicare certified, a current copy of the certification. 5. Seller's Certification for a Pharmacy (17A-8) (If applicable) This is only required for an application for a change of ownership and it must be submitted by the prospective owner(s). Section B [] Individual Owner 1. Certification of Personnel (17A-11) for the: · · · Professional Director Administrator Consulting Pharmacist [] 2. Copy of Request for Live Scan Service Form verifying that fingerprints have been scanned and all applicable fees have been paid for: Please refer to fingerprint instructions on page 6. · · Professional Director Administrator Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Section C [] [] Partnership 1. A copy of the partnership agreement. 2. Certification of Personnel (17A-11) for the: · · · Professional Director Administrator Consulting Pharmacist [] 3. Copy of Request for Live Scan Service Form verifying that fingerprints have been scanned and all applicable fees have been paid for: Please refer to fingerprint instructions on page 6. · · Professional Director Administrator Section D [] [] Corporation 1. Articles of Incorporation endorsed by the Secretary of State. 2. Certification of Personnel (17A-11) for the: · · · Professional Director Administrator Consulting Pharmacist [] 3. Copy of Request for Live Scan Service Form verifying that fingerprints have been scanned and all applicable fees have been paid for: Please refer to fingerprint instructions on page 6. · · Professional Director Administrator Page 3 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Section E [] [] Limited Liability Company 1. Articles of Organization endorsed by the Secretary of State. 2. Certification of Personnel (17A-11) for the: · · · Professional Director Administrator Consulting Pharmacist [] 3. Copy of Request for Live Scan Service Form verifying that fingerprints have been scanned and all applicable fees have been paid for: Please refer to fingerprint instructions on page 6. · · Professional Director Administrator State, City, or County Owned Clinic Section F [] [] 1. Application (17A-42) (no fee required) 2. Completed Certification of Personnel (17A-11) for: a. Professional Director b. Administrator c. Consulting Pharmacist [] [] [] 3. A letter of verification from the county public health department or the board of supervisors indicating that the facility is government owned 4. The name of the Director of Public Health or the responsible party for the clinic operation 5. A copy of the organizational structure Section G [] [] Indian Owned 1. Application (17A-42) and the non-refundable processing fee of $400. 2. Official documents from the U.S. Department of Interior, Bureau of Indian Affairs, identifying the official tribe. Page 4 of 6 American LegalNet, Inc. www.FormsWorkFlow.com [] [] [] [] 3. A copy of the constitution and by-laws establishing the tribal council that will be the governing entity of the clinic. 4. Certification of Personnel (17A-11) for the tribal council members and the administrator/CEO. 5. Certification of Personnel (17A-11) for the consulting pharmacist. 6. Copy of Request for Live Scan Service Form verifying fingerprints for the tribal council and the administrator/CEO have been scanned and all applicable fees have been paid. Please refer to fingerprint instructions on page 6. Non-Indian owned but operating on tribal lands Section H If the non-Indian owner is a corporation: [] [] [] [] 1. All requirements listed in Section A. 2. Articles of incorporation endorsed by the Indian tribe. 3. Statement by domestic stock endorsed by the Indian tribe. 4. AND all other requirements of corporate owners listed in section D, (except the articles of incorporation and the statement by domestic stock must be endorsed by the Indian tribe and not by the Secretary of State). If the non-Indian owner is a sole owner or partnership: [] [] [] 1. All requirements listed in Section A. 2. Documents describing the agreements with the Indian tribe to operate the clinic on tribal land. 3. AND all other requirements of sole owners or partnership listed in Section B or Section C respectively. Change of Location ONLY (no ownership change) Section I [] [] 1. Application (17A-42) and the non-refundable processing fee of $100. 2. Certification of Personnel (17A-11) for the: · ·
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