"Application for Pharmacy - Institutional License and Controlled Substances Registration" - Rhode Island

This "Application for Pharmacy - Institutional License and Controlled Substances Registration" is a document issued by the Rhode Island Department of Health specifically for Rhode Island residents with its latest version released on May 16, 2013.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Rhode Island Department of Health.

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Download "Application for Pharmacy - Institutional License and Controlled Substances Registration" - Rhode Island

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*** Submit This Cover Page With Application ***
***FOR OFFICE USE ONLY***
Receipt #:
ID#:
Issue Date:
License #
PHB
CPHB
Rhode Island
Board of Pharmacy
Room 103
3 Capitol Hill
Providence, RI 02908-5097
Instructions and Application For
Pharmacy - Institutional License
and
Controlled Substances Registration
New Application
Change of Location (License # __________ )
Controlled Substances Registration
Change in Ownership (License # _________ )
Practice Specialty:
Hospital
HMO
Applicant - Print Pharmacy/Facility Name
Phone: (401) 222-2837
TTY/TDD: (800) 745-5555
Fax: (401) 222-2158
Revised 05/16/2013 jcp
*** Submit This Cover Page With Application ***
***FOR OFFICE USE ONLY***
Receipt #:
ID#:
Issue Date:
License #
PHB
CPHB
Rhode Island
Board of Pharmacy
Room 103
3 Capitol Hill
Providence, RI 02908-5097
Instructions and Application For
Pharmacy - Institutional License
and
Controlled Substances Registration
New Application
Change of Location (License # __________ )
Controlled Substances Registration
Change in Ownership (License # _________ )
Practice Specialty:
Hospital
HMO
Applicant - Print Pharmacy/Facility Name
Phone: (401) 222-2837
TTY/TDD: (800) 745-5555
Fax: (401) 222-2158
Revised 05/16/2013 jcp
***Detach Page - Do Not Submit With Application ***
GENERAL INFORMATION
Enclosures
The following materials and information should be enclosed within this application packet:
Application Process Overview........................................................................................................... 3
Instructions for Completing Application..............................................................................................5
Application Materials
Application.............................................................................................................................. 6-10
Application Checklist.............................................................................................................. 11
Termination as Pharmacist-in-Charge Report & Information (Save for Future Use)............12-13
Licensure Requirements
• Application Fee of $220.00 (add $100.00 for Controlled Substances Registration for a total of $320.00)
Check or money order only (NOTE: All application fees are non-refundable)
• Federal Drug Enforcement Administration (DEA) Registration (if applicable)
• Pharmacist-in-Charge
• Blueprint or Floor Plan Drawings (for new pharmacy or change of location only)
• Inspection (for new pharmacy or change of location only)
Pharmacist-in-Charge
The pharmacist-in-charge is a pharmacist licensed in this state that is designated by the owner as the person
responsible for the operation of a pharmacy, and who is personally in full and actual charge of such pharmacy
and personnel. The pharmacist-in-charge is responsible for meeting the requirements set forth by federal and
state law, the Pharmacy Act, and other applicable regulations of the BOARD.
Physician ownership
The Board of Pharmacy shall refuse to grant any pharmacy license to any person who is a practitioner
authorized to prescribe medications or to any partnership, corporation or other entity in which practitioners
authorized to prescribe medications maintain a financial interest which, in the aggregate, exceeds ten percent
(10%) of the total ownership of said entity or of the subject pharmacy or drug store. “Financial interest” means
financial benefit gained by any practitioner with authority to prescribe drugs and includes such benefit derived
by a spouse or dependent child. Information regarding practitioner ownership and financial interest
must be provided along with this application.
On and after July 1, 1994, good and sufficient cause shall exist for the refusal to renew and/or for the
revocation of any pharmacy license, if, after hearing, the Board of Pharmacy determines that:
i. Practitioners, spouse (if not estranged) or any dependent child or business associate of the person
with authority to prescribe medications maintain a financial interest, which, in the aggregate, exceeds
ten percent (10%) of the total ownership of the subject pharmacy, drug store or licensee; or
ii. More than forty percent (40%) of the prescriptions filled by the subject pharmacy or drug store within
any three (3) month period beginning on or after July 1, 1994 were issued by practitioners with any
ownership interest in a drug store or licensee.
a. The pharmacist-in-charge of said pharmacy shall furnish and deliver to the Board, upon
request, all dispensing reports, and any other required documents necessary to determine the
percentage of prescriptions filled.
Rhode Island Board of Pharmacy - Page 2
***Detach Page - Do Not Submit With Application ***
APPLICATION PROCESS OVERVIEW
The licensure process in the State of Rhode Island is conducted by the Rhode Island Department of Health
(HEALTH), Office of Health Professions Regulation, and the Rhode Island Board of Pharmacy (BOARD).
Application Process
This application is to be used for a new institutional pharmacy, and to apply for a new license due to a change
in ownership or location. Copies of the current continuing education credits for the pharmacist-in-charge must
accompany this application. A pharmacy license will be issued to a person, owner, corporation, or other legal
entity, hereinafter called the “Licensee”. The license shall entitle the owner to operate such pharmacy at the
location specified and shall not be transferred. The license shall be posted in a conspicuous place on the
licensed premises. When there is a change in ownership, operation and/or location, the license immediately
becomes void and shall be delivered by the licensee to the BOARD. It is the duty of the owner to immediately
notify the BOARD of any proposed change of location or ownership, and to file the required application prior to
the change.
“Change of ownership” means:
a. In the case of a pharmacy, manufacturer or wholesaler which is a partnership which results in a new
partner acquiring a controlling interest in the partnership;
b. In the case of a pharmacy, manufacturer or wholesaler which is a sole proprietorship, the transfer of
the title and property to another person;
c. In the case of a pharmacy, manufacturer or wholesaler which is a corporation:
i. A sale, lease exchange, or other disposition of all, or substantially all of the property and
assets of the corporation; or
ii. A merger of the corporation into another corporation; or
iii. The consolidation of two or more corporations, resulting in the creation of a new corporation; or
iv. In the case of a pharmacy, manufacturer or wholesaler which is a business corporation, any
transfer of corporate stock which results in a new person acquiring a controlling interest in
the corporation; or
v. In the case of a pharmacy, manufacturer or wholesaler which is a nonbusiness corporation,
any change in membership which results in a new person acquiring a controlling vote in the
corporation.
Renovating or remodeling an existing pharmacy is not considered a change of location. Written notification to
the BOARD is required prior to the renovations or remodeling, stipulating the expected date of completion, and
accompanied by the blueprints of the proposed changes.
All items listed on the “checklist” (page 11) must be submitted for an application to be considered complete. All
applications are considered valid for six months from the day they are received at HEALTH. If you do not
complete the application process and obtain a license within those six months, a new application and fee must
be submitted.
A new pharmacy, or a relocation of an existing pharmacy, must be inspected prior to the issuance of a license.
It is the applicant’s responsibility to contact the BOARD to schedule an inspection. Please allow a minimum of
four weeks for the entire licensure process to be completed. If the applicant has had criminal or disciplinary
history in Rhode Island or another state, it may take an additional two or three months for all pertinent
documentation to be received, and a decision to be made regarding the issuance of a license. This is an
estimate of the amount of time that is required to become licensed. The entire process may take more or less
time than estimated.
Rhode Island Board of Pharmacy - Page 3
***Detach Page - Do Not Submit With Application ***
APPLICATION PROCESS OVERVIEW
(continued)
Licenses will be issued within five working days following the Board’s approval of the completed application.
Wall permits are mailed approximately two weeks from the date of issuance, and are mailed to the address
furnished in the application. It is the applicant’s responsibility to notify the BOARD, in writing, if there are
changes during the interim, or at any time after the license is issued. It is the responsibility of the licensee to
notify the BOARD in writing when there is a change in the pharmacist-in-charge. At no time can a pharmacy
operate without a designated pharmacist-in-charge on file with the BOARD.
HEALTH will not, for any reason, accelerate processing of one applicant at the expense of other applicants.
Once completed, the application will be reviewed, and will be contacted by the BOARD if further information is
required. Be advised, the applicant may be required to appear for an interview.
NOTE:
Licensure application materials are public records as mandated by Rhode Island law and may be made
available to the public, unless otherwise prohibited by State or Federal Law.
The license will expire on September 30th (regardless of the date issued), and a form will be mailed to renew
the pharmacy license for the period October 1st through September 30th. It is the licensee’s responsibility to
maintain an active license. If a renewal is not received, the licensee is to contact the BOARD to follow-up on
the status of the renewal:
https://healthri.mylicense.com/Verification/
Please continue to review the remaining portions of this application packet for instructions and other materials
necessary to complete the Board application. If you have any questions about this application process, or
would like to check on the status of your BOARD application, please contact the BOARD at (401) 222-2837.
Rules and Regulations
To obtain the Rules and Regulations for your profession visit the A-Z list on the Topics & Programs page at the
following web site. From the list click on the letter for your profession.
http://www.health.ri.gov/atoz/
Rhode Island Board of Pharmacy - Page 4
***Detach Page - Do Not Submit With Application ***
INSTRUCTIONS FOR COMPLETING THE BOARD APPLICATION
Read the following instructions and those throughout the application packet carefully before completing the
Board application. Only complete applications with the appropriate fee will be accepted. Failure to
submit all required information and appropriate documentation may result in processing delays. All of the
information provided is subject to change.
General Instructions
1. Make a copy of the application and forms before you begin in case you make a mistake.
2. Type the information or print in blue or black ball-point pen. Board staff will not make assumptions about
illegible information. Be sure to print the licensee’s name in the box provided on the cover page.
3. Provide a response to each section or question; otherwise mark “N/A” for Not Applicable.
4. It is suggested that a copy of the completed application be made before submitting it to the Board.
5. It is the applicant’s responsibility to check on the status of the application.
Completing your Board Application
1. Complete the Board Application pages (6-10). Respond to all components of the application as
instructed. If you attach separate pages in continuation of the Board application, such pages MUST clearly
indicate the section for which such information is being reported.
2. Make a check or money order (in U.S. Funds only) for the application fee of $220.00 (or $320.00 with CSR
application) payable to General Treasurer, State of Rhode Island and staple it to the upper left-hand
corner of the cover page of the application.
A Controlled Substances Registration (CSR) is mandatory for all new pharmacies that will dispense
controlled substances. The fees are NONREFUNDABLE. A Drug Enforcement Administration (DEA)
Registration is also required. Contact the DEA at 617-557-2200 for the application
http://www.deadiversion.usdoj.gov./drugreg/reg_apps/index.html
The RI CSR is contingent upon a DEA Registration being issued.
Complete all application materials as instructed and arrange them in order as they appear in the application
checklist
(see page
11). Do not submit applications without all applicable information, documentation and fee.
Mail these components of the application to:
Rhode Island Department of Health
Board of Pharmacy, Room 103
3 Capitol Hill
Providence, RI 02908-5097
Rhode Island Board of Pharmacy - Page 5
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