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Instructions For Filing A Hospital Application 17A-46 - California
| Instructions For Filing A Hospital 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 N-219 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. INSTRUCTIONS FOR FILING A HOSPITAL PHARMACY APPLICATION Inpatient, Outpatient, Exempt (100 beds or fewer) 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. Please allow approximately 90 days from the time your application packet is complete before calling the Board of Pharmacy. 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 Requirements for all applicants except government owned, Native American tribe owned, non-Native American owned but operating on tribal lands, or change of location. Note: All pharmacy change of ownership applications will be considered for temporary permits. Whenever a change of ownership occurs, either a temporary permit will be pursued or operation must stop. In addition to the regular items required for this application, a $250.00 temporary permit fee must also be submitted. 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 application who is filing as a limited liability company Requirements for state, city or county owned hospital Requirements for Native American tribe owned clinic Requirements for non-Native American owned but operating on tribal lands Requirements for exempt hospital (100 beds or fewer) Requirements for change of location only (no ownership change) CHECKLIST FOR FILING A HOSPITAL PHARMACY APPLICATION Section A [] [] All Applicants Section B Section C Section D Section E Section F Section G Section H Section I 1. Application (17A-19) and the non-refundable processing fee of $400. 2. Ownership form a. b. Corporation OR Limited Liability Company (17A-33 ) OR Partnership or Individual (17A-34) Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com [] 3. Financial Affidavit in Support of Application (17A-2) (Not needed for a change of location or non-profit organization) 4. Approved wholesale credit application or wholesale agreement (Not needed for non-profit organization) 5. Copy of the lease agreement 6. 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). 7. Please provide a copy of your hospital acute care license issued by the Department of Health Services. 8. If you are a Knox Keene provider, please provide a copy of your current Department of Corporations license. 9. If the pharmacy is not operated by the hospital, provide a signed copy of the management agreement. Partnership [] [] [] [] [] [] Section B [] 1. Each partner must submit: Certification of Personnel (17A-11) Individual Personal Affidavit (17A-27) Individual Financial Affidavit (form 17A-26) Copy of Request for Live Scan Service Form verifying that your fingerprints have been scanned and all applicable fees have been paid. Please refer to fingerprint instructions on page 7. [] 2. Certification of Personnel (17A-11) for the pharmacist-in-charge or consulting pharmacist 3. Signed Partnership Agreement If the partners are a corporation or a limited liability company (LLC), then complete and provide the same documents required of corporations (see section C). [] Section C Corporation The first line corporation over the pharmacy needs to complete a form 17A-33. Each remaining parent corporation, over the first line corporation, needs to complete a form 17A33A. Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com For Profit For the named corporation on the application, or person(s) who owns an interest in, the corporation named on the application, the following is required: [] 1. Each corporate officer, major shareholder, and director must submit: Certification of Personnel (17A-11) Individual Personal Affidavit (17A-27) Individual Financial Affidavit (form 17A-26) Copy of Request for Live Scan Service Form verifying that your fingerprints have been scanned and all applicable fees have been paid. Please refer to fingerprint instructions on page 7. [] [] [] 2. Certification of Personnel (17A-11) for the pharmacist-in-charge 3. Articles of Incorporation endorsed by the Secretary of State. 4. Statement a. Statement of Information endorsed by the Secretary of State. An endorsed copy must be requested from the Secretary of State. OR b. Statement by Foreign Corporation endorsed by the California Secretary of State. This is only required if the named corporation on the application is incorporated outside of California. [] 5. By-laws Non-Profit For the named corporation on the application and any corporation that is the parent of, or who owns an interest in, the corporation named on the application, the following is required: [] [] [] [] 1. Statement of Information endorsed by the Secretary of State. 2. By-laws 3. Articles of Incorporation endorsed by the Secretary of State. 4. Each corporate officer, shareholder, and director must submit: Certification of Personnel (17A-11) [] 5. Certification of Personnel (17A-11) for the pharmacist-in-charge Page 3 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Publicly Traded Corporation [] [] 1. A copy of the corporation's 10K filing with the Securities Exchange Commission. 2. A list of the five largest shareholders who own 5% or more of stock which requires a filing with the Securities Exchange Commission. If the shareholder is an individual, include name, title and professional license (if applicable). Also, identify if the shareholder is a bank, trust company or financial institution to which a license is issued in a fiduciary capacity. Section D Limited Liability Company (LLC) In addition to items listed in Section A, the following must be submitted: The first line limited liability company over the pharmacy needs to complete a form 17A-33A. Each remaining company over the first line limited liability company also needs to complete a form 17A-33A. [] 1. Each member/manager must submit: Certification of Personnel (17A-11) Individual Personal Affidavit (17A-27) Individual Financial Affidavit (form 17A-26) Copy of R
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