California > Statewide > Board Of Pharmacy
Hospital Pharmacy Permit Application 17A-19 - California
| Hospital Pharmacy 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 N. 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 ARNOLD SCHWARZENEGGER, GOVERNOR HOSPITAL PHARMACY PERMIT APPLICATION Inpatient, Outpatient, Exempt (100 beds or fewer) Please type or print All blanks must be completed; if not applicable enter N/A Name of hospital: Address of hospital: Mailing address: (if different from above) Type of pharmacy: Hospital telephone number: Number and Street City State Zip Code Number and Street City State Zip Code Inpatient Outpatient (check all that apply) ____Retail Exempt (100 beds or fewer) ____Home Health Care ____Skilled Nursing Facility This application is for: New Pharmacy Change of Location of an existing pharmacy Change of Ownership of an existing pharmacy If change of ownership or change of location, indicate previous name, address and license number Name: Address: License Number: Type of Ownership: Individual Partnership Corporation ___Not-for-profit Limited Liability Company No Government Is the pharmacy located at the primary hospital address? If No, please provide the address of the hospital: Yes Other areas of the hospital where drugs are stored: (Check all that apply) Nursing Station Continue on Reverse Satellite pharmacy Drug/Night Locker Emergency Room Other: For office use only Staff Review Articles of Incorp Partner Agreement Seller's cert Dep. Corp Lic Financial Aff Domestic Stock By-laws Cashiering Approved Denied Date Page 1 of 3 Cashier # Date Amount of fee American LegalNet, Inc. www.FormsWorkflow.com Department of Health Services license number: Is the pharmacy operated by the hospital? Yes No Number of beds : (exempt hospitals only) If No, please provide the name, address and telephone number of management company: Name of management company Address: Telephone number: Contact person: Were you qualified as a Knox-Keene provider before August 1, 1981? Yes No If yes, please provide a copy of your current license from the Department of Corporations (Section 4111(d)) Are the pharmacy premises leased, rented or occupied under any agreement with any person who is licensed in California to prescribe? Yes No Will this pharmacy dispense replacement contact lenses to patients? Yes No By your affirmative answer above, your hospital pharmacy name will be provided to the California Medical Board and you will be in compliance with section 4124 of the California Business and Professions Code. Anticipated first day of business: Name of contact person: Name of pharmacist-in-charge: Address of pharmacist-in-charge: Number & Street City State Zip Code Exempt Hospital Only Do you employ a full-time registered pharmacist? If yes, provide name of pharmacist: If no, provide name of consulting pharmacist: Residence address of consulting pharmacist: Name of Medical Director: Residense address: Name of Administrator: Residence address: License number: Yes No License number: License number: Number & Street City State Zip Code Number & Street City State Zip Code Continue on next page Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com PLEASE READ CAREFULLY AND SIGN BELOW This application must be approved by the California State Board of Pharmacy before a pharmacy permit will be issued. If changes are made during the application process, you may need to submit a new application with the appropriate fees. Any application not completed within 60 days of receipt may be deemed withdrawn by the Board of Pharmacy. Fees applied to this application are not transferable and are not refundable. Any material misrepresentation in the answer of any question is grounds for refusal or subsequent revocation of a license, and is a violation of the Penal Code of California. All items of information requested in this application are mandatory. Failure to provide any of the requested information will result in the application being rejected as incomplete. The information will be used to determine qualifications for licensure under California Pharmacy Law. The officer responsible for information maintenance is the executive officer, (916) 574-7900, 1625 N. Market Blvd, Suite N219, Sacramento, California 95834. The information may be transferred to another governmental agency such as a law enforcement agency if necessary for it to perform its duties. Each individual has the right to review the files or records maintained on him/her by the Board of Pharmacy, unless the records are identified as confidential information and exempted by section 1798.3 of the Civil Code. ALL OWNERS AND OFFICERS MUST SIGN BELOW Under penalty of perjury, under the laws of the State of California, each person whose signature appears below, certifies and says that: (1) he/she is the owner or an officer of the applicant corporation named in the foregoing application, duly authorized to make this application on its behalf and is at least 18 years of age; (2) he/she has read the foregoing application and knows the contents thereof and that each and all statements therein made are true; (3) no person other than the applicant or applicants has any direct or indirect interest in the applicant(s) business to be conducted under the license(s) for which this application is made; (4) all supplemental statements are true and accurate; and (5) the transfer application may be withdrawn by either the applicant or the licensee with no resulting liability to the Board of Pharmacy. Inpatient and Outpatient Hospitals (100 beds or more) Signature of Corporate Officer or Owner Signature of Corporate Officer or Owner Signature of Corporate Officer or Owner Signature of Corporate Officer or Owner Print Name Print Name Print Name Print Name Date Date Date Date Exempt Hospitals Only (100 beds or fewer) Signature of Administrator Signature of Pharmacist-in-Charge Print Name Print Name Date Date 17A-19 (6/04) Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com
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