Form DBPR-DDC-224 "Application for Permit as a Health Care Clinic Establishment" - Florida

What Is Form DBPR-DDC-224?

This is a legal form that was released by the Florida Department of Business & Professional Regulation - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2016;
  • The latest edition provided by the Florida Department of Business & Professional Regulation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DBPR-DDC-224 by clicking the link below or browse more documents and templates provided by the Florida Department of Business & Professional Regulation.

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Download Form DBPR-DDC-224 "Application for Permit as a Health Care Clinic Establishment" - Florida

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State of Florida
Department of Business and Professional Regulation
Division of Drugs, Devices, and Cosmetics
Application for Permit as a Health Care Clinic Establishment
Form No.: DBPR-DDC-224
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
Submit a biennial application fee of $255.00, made payable by cashier’s
check, corporate or business check, or money order, to the Florida
Application for
Department of Business and Professional Regulation.
Permit as a Health
Care Clinic
If you answer “Yes” to any question in Section IV, be sure to provide a
detailed explanation along with any relevant documentation.
Establishment
Sign and date the Affidavit section of the application.
Submit the completed application with enclosures to:
Department of Business and Professional Regulation
1940 North Monroe Street
Tallahassee, FL 32399
PLEASE NOTE:
Telephone, email, and fax contact information is used to quickly resolve questions with applications. If
such information is not provided, questions regarding applications will be mailed to the application
contact’s mailing address and may take longer to resolve.
DBPR-DDC-224 - Application for Permit as a Health Care Clinic Establishment
Incorporated by rule: 61N-2.006, F.A.C.
Eff. Date: April 2016
Page 1 of 8
State of Florida
Department of Business and Professional Regulation
Division of Drugs, Devices, and Cosmetics
Application for Permit as a Health Care Clinic Establishment
Form No.: DBPR-DDC-224
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
Submit a biennial application fee of $255.00, made payable by cashier’s
check, corporate or business check, or money order, to the Florida
Application for
Department of Business and Professional Regulation.
Permit as a Health
Care Clinic
If you answer “Yes” to any question in Section IV, be sure to provide a
detailed explanation along with any relevant documentation.
Establishment
Sign and date the Affidavit section of the application.
Submit the completed application with enclosures to:
Department of Business and Professional Regulation
1940 North Monroe Street
Tallahassee, FL 32399
PLEASE NOTE:
Telephone, email, and fax contact information is used to quickly resolve questions with applications. If
such information is not provided, questions regarding applications will be mailed to the application
contact’s mailing address and may take longer to resolve.
DBPR-DDC-224 - Application for Permit as a Health Care Clinic Establishment
Incorporated by rule: 61N-2.006, F.A.C.
Eff. Date: April 2016
Page 1 of 8
State of Florida
Department of Business and Professional Regulation
Division of Drugs, Devices, and Cosmetics
Application for Permit as a Health Care Clinic Establishment
Form No.: DBPR-DDC-224
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Division of Drugs, Devices and Cosmetics, at
850.717.1800. For additional information see the instructions at the beginning of this application.
Section I – Application Type
CHECK ONE OF THE APPLICATION TYPES
New Application [3360/1020]
New Application due to Change in Ownership. If checked, provide legal documentation for the
change of ownership (i.e. Bill of Sale, stock transfer, merger). [3360/1020]
Current Permit Number: ___________________________
Section II – Applicant Information
APPLICANT INFORMATION
TAXPAYER IDENTIFICATION NUMBER OR FEDERAL EMPLOYER IDENTIFICATION NUMBER
This is a unique nine-digit number assigned by the Internal Revenue Service (IRS) to business entities
operating in the United States for the purposes of identification. When the number is used for
identification rather than employment tax reporting, it is usually referred to as a Taxpayer Identification
Number (TIN), and when used for the purposes of reporting employment taxes, it is usually referred to as
the Federal Employer Identification Number (FEIN).
Applicant’s TIN/FEIN:
FULL LEGAL NAME
The “full legal name” is the complete name of the business entity that will be operating the establishment.
This is generally the name that is on the documents that establish the existence or formation of the
business entity. For example, a corporation’s full legal name would normally be the name that is found in
the corporation’s articles of incorporation.
Applicant’s Full Legal Name:
FICTITIOUS, TRADE, OR BUSINESS NAME
If the applicant intends to operate the permitted establishment under a name that is different from the
Applicant’s Full Legal Name listed above – e.g. fictitious, trade, or business name (also commonly
referred to as a “dba”, “D/B/A”, or “doing business as” name – this name must be registered with the
Florida Department of State, Division of Corporations. This is the name that will appear on the permit
issued to the applicant by the department and must be the name that the applicant uses on operational
documents for permitted activities.
The applicant WILL NOT operate the permitted establishment under a name that is different from the
Applicant’s Full Legal Name listed above.
The applicant WILL operate the permitted establishment under the following fictitious, trade, or
business name:
___________________________________________________________________
The fictitious, trade, or business name listed directly above, is registered with the Florida Department
of State, Division of Corporations and the applicant has been issued the following registration
number:
______________________________.
DBPR-DDC-224 - Application for Permit as a Health Care Clinic Establishment
Incorporated by rule: 61N-2.006, F.A.C.
Eff. Date: April 2016
Page 2 of 8
APPLICANT’S MAILING ADDRESS
Street Address or P.O. Box:
City:
State:
Zip Code (+4 optional):
PHYSICAL ADDRESS OF ESTABLISHMENT TO BE PERMITTED
(only if different from mailing address) Check
if not applicable
Street Address:
City:
State:
Zip Code (+4 optional):
County (if Florida address):
Country:
E-Mail Address:
Phone Number:
Fax Number:
APPLICATION CONTACT
The application contact is the person that the department will contact if there are questions regarding the
responses provided on, or the documentation submitted with, the application. The application contact is
also the person that will receive all official communication from the department regarding the application.
Last/Surname:
First:
Middle:
Suffix:
Address:
City:
State:
Zip Code (+4 optional):
Telephone Number:
Fax Number:
E-Mail Address:
DESIGNATED QUALIFYING PRACTITIONER
The designated qualifying practitioner is the person that the department will contact regarding legal and or
regulatory issues related to the purchase, recordkeeping, storage, and handling of prescription drugs.
The department will contact this person at times outside of the regular business hours listed below. The
contact information provided should be sufficient for the department to actually reach and communicate
with the designated qualifying practitioner.
Last/Surname:
First:
Middle:
Suffix:
Street Address:
City:
State:
Zip Code (+4 optional):
Telephone Number:
E-Mail Address:
License # With Prefix:
Expiration Date:
Issuing regulatory board (e.g.: Florida Board of
Medicine):
___ / _____ / _______
Is qualified practitioner authorized under the appropriate practice act to prescribe and
Yes
No
administer prescription drugs? If no, please explain.
Explanation Attached?
Yes
No
N/A
DBPR-DDC-224 - Application for Permit as a Health Care Clinic Establishment
Incorporated by rule: 61N-2.006, F.A.C.
Eff. Date: April 2016
Page 3 of 8
Qualifying Practitioner Affidavit:
I UNDERSTAND that as the qualifying practitioner I will be responsible for complying with all legal and
regulatory requirements related to the purchase, recordkeeping, storage, and handling of the prescription
drugs.
I UNDERSTAND that my name, the establishment address, and my license number will be used on all
distribution documents for prescription drugs purchased or returned by the health care clinic
establishment.
I UNDERSTAND that a violation of Chapter 499, Florida Statutes, by the health care clinic establishment
or me as the qualifying practitioner constitutes grounds for discipline of my health care practitioner license
by the appropriate regulatory board.
Signature of Designated Qualifying Practitioner:
Date:
OPERATING HOURS
List the establishment’s daily hours of operation in terms of Eastern Time. REMEMBER to circle “a.m.” or
“p.m.” for each time indicated below.
Mon
:
a.m./p.m. to
:
a.m./p.m.
Fri
:
a.m./p.m. to
:
a.m./p.m.
Tue
:
a.m./p.m. to
:
a.m./p.m.
Sat
:
a.m./p.m. to
:
a.m./p.m.
Wed
:
a.m./p.m. to
:
a.m./p.m.
Sun
:
a.m./p.m. to
:
a.m./p.m.
Thu
:
a.m./p.m. to
:
a.m./p.m.
Section III – Ownership Information
TYPE OF OWNERSHIP
Publicly Held Corporation
Closely Held Corporation
Limited Liability Company
Charitable Organization—501(c)(3)
Sole Proprietorship
Government
Partnership – General
Professional Corporation
Professional Limited
or Association
Liability Company
Partnership – Other, Including
Limited Liability Partnership and
Other:__________________
Limited Partnership
List the state of incorporation or state of organization (except Partnership – General or Sole
Proprietorship). Business entities organized under non-U.S. laws list the country of organization.
N/A (Partnership – General or Sole Proprietorship)
State or Country:
DBPR-DDC-224 - Application for Permit as a Health Care Clinic Establishment
Incorporated by rule: 61N-2.006, F.A.C.
Eff. Date: April 2016
Page 4 of 8
List name and address of the applicant’s registered agent for service of process in Florida (except Sole
Proprietorship or Partnership – General) and provide documentation, such as a print out from the Florida
Department of State, Division of Corporations’ webpage, that the applicant’s registered agent is
registered with the Florida Department of State, Division of Corporations.
N/A (Partnership – General or Sole Proprietorship)
Name:
Address:
City:
State:
Zip Code (+4 optional):
List the name, position/title, social security number, date of birth and address of each owner, partner,
member, manager, officer, director, chief executive, or other person who directly or indirectly controls the
operation of the business entity, as applicable. For example, corporations would list officers and
directors, limited liability companies would list members and managers, etc.
1.
Name & Title:
Social Security #:
Date of Birth:
% of Ownership:
Street Address:
City:
State:
Zip Code:
2.
Name & Title:
Social Security #:
Date of Birth:
% of Ownership:
Street Address:
City:
State:
Zip Code:
3.
Name & Title:
Social Security #:
Date of Birth:
% of Ownership:
Street Address:
City:
State:
Zip Code:
4.
Name & Title:
Social Security #:
Date of Birth:
% of Ownership:
Street Address:
City:
State:
Zip Code:
5.
Name & Title:
Social Security #:
Date of Birth:
% of Ownership:
Street Address:
City:
State:
Zip Code:
List the name, social security number, date of birth and address of each person who owns 10 percent or
more of the outstanding stock or equity interest in the business entity.
1.
Name:
Social Security #:
Date of Birth:
% of Ownership:
Street Address:
City:
State:
Zip Code:
DBPR-DDC-224 - Application for Permit as a Health Care Clinic Establishment
Incorporated by rule: 61N-2.006, F.A.C.
Eff. Date: April 2016
Page 5 of 8