"Application for a Facility Permit for Practitioner(S) of the Healing Arts to Sell Controlled Substances" - Virginia

Application for a Facility Permit for Practitioner(S) of the Healing Arts to Sell Controlled Substances is a legal document that was released by the Virginia Department of Health Professions - a government authority operating within Virginia.

Form Details:

  • Released on October 1, 2020;
  • The latest edition currently provided by the Virginia Department of Health Professions;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Virginia Department of Health Professions.

ADVERTISEMENT
ADVERTISEMENT

Download "Application for a Facility Permit for Practitioner(S) of the Healing Arts to Sell Controlled Substances" - Virginia

Download PDF

Fill PDF online

Rate (4.5 / 5) 19 votes
9960 Mayland Drive, Suite 300
Henrico, Virginia 23233
(804) 367-4456 (Tel)
(804) 527-4472 (Fax)
pharmbd@dhp.virginia.gov
www.dhp.virginia.gov/pharmacy
APPLICATION FOR A FACILITY PERMIT FOR PRACTITIONER(S) OF
THE HEALING ARTS TO SELL CONTROLLED SUBSTANCES
Check Appropriate Box(es):
1
1
New, more than one practitioner selling at location
$315.00
Change of location of selling area
$300.00
1
1
New, only one practitioner selling at location
No fee
Remodel of selling area
$300.00
3
2
Reinstatement
Call Board
Change in designated practitioner
No fee
Reinstatement after suspension or revocation
$650.00
Change in name of practice
No fee
Application fees are not refundable. Applications are valid for one year from the date of receipt.
The required fees must accompany the application. Make check payable to “Treasurer of Virginia”.
Name of Facility/Practice
Street Address Where Applicant Wishes to Sell Controlled Substances
Fax Number
City
State
Zip Code
If a current facility permit to sell controlled substances is held, indicate the permit number:
Telephone Number (currently working number)
0224-
2
2
Print Name of the Responsible Designated Practitioner for Facility
Medical License Number
0101-
License Number of the Designated Practitioner
Email Address of Responsible Designated Practitioner for Facility
0213-
2
Signature of the Responsible Designated Practitioner for Facility
Date
Expected Hours of Operation
Effective Date of Change for designated practitioner (if applicable)
Expected Opening, Moving, or Completion Date (if applicable)
Requested Inspection Date (if applicable)
3
REINSTATEMENT ONLY
:
Have controlled substances been sold from the location at the address on this application during the time
that the facility permit was lapsed?
Yes
No
If yes, attach explanation.
10-2020
9960 Mayland Drive, Suite 300
Henrico, Virginia 23233
(804) 367-4456 (Tel)
(804) 527-4472 (Fax)
pharmbd@dhp.virginia.gov
www.dhp.virginia.gov/pharmacy
APPLICATION FOR A FACILITY PERMIT FOR PRACTITIONER(S) OF
THE HEALING ARTS TO SELL CONTROLLED SUBSTANCES
Check Appropriate Box(es):
1
1
New, more than one practitioner selling at location
$315.00
Change of location of selling area
$300.00
1
1
New, only one practitioner selling at location
No fee
Remodel of selling area
$300.00
3
2
Reinstatement
Call Board
Change in designated practitioner
No fee
Reinstatement after suspension or revocation
$650.00
Change in name of practice
No fee
Application fees are not refundable. Applications are valid for one year from the date of receipt.
The required fees must accompany the application. Make check payable to “Treasurer of Virginia”.
Name of Facility/Practice
Street Address Where Applicant Wishes to Sell Controlled Substances
Fax Number
City
State
Zip Code
If a current facility permit to sell controlled substances is held, indicate the permit number:
Telephone Number (currently working number)
0224-
2
2
Print Name of the Responsible Designated Practitioner for Facility
Medical License Number
0101-
License Number of the Designated Practitioner
Email Address of Responsible Designated Practitioner for Facility
0213-
2
Signature of the Responsible Designated Practitioner for Facility
Date
Expected Hours of Operation
Effective Date of Change for designated practitioner (if applicable)
Expected Opening, Moving, or Completion Date (if applicable)
Requested Inspection Date (if applicable)
3
REINSTATEMENT ONLY
:
Have controlled substances been sold from the location at the address on this application during the time
that the facility permit was lapsed?
Yes
No
If yes, attach explanation.
10-2020
Practitioner Selling Drugs Application, Page 2
1
A 14-day notice is required for scheduling an inspection.
Drugs may not be stocked prior to inspection and approval of the drug selling and storage area.
2
18 VAC 110-30-70 requires a facility with a permit for practitioners of the healing arts to sell controlled
substances to designate a practitioner with a license to sell controlled substances who shall be the primary
person responsible for the stock, the required inventory, the records of receipt and destruction, safeguards
against diversion and compliance with the chapter.
3
Reinstatement fee is determined by the Board based on the length of time the license has been lapsed unless
reinstatement after suspension or revocation.
An inspector will call prior to the requested date to confirm readiness for inspection. If the inspector does
not call to confirm the date, the responsible party should call the Enforcement Division at (804) 367-4691 to
verify the inspection date with the inspector.
FOR OFFICE USE ONLY:
Date processed:
Check No:
Receipt No:
Application No:
Date Issued:
Permit Number
Reviewed/Issued by:
Date Sent to PMP:
0224-
10-2020
Page of 2