Fillable Centralized Prescription Handling Pharmacy Service Joint Application to (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Centralized Prescription Handling Pharmacy Service Joint Application to (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Board of Pharmacy
124 Halsey Street, 6th Floor, Newark, NJ 07102
(973) 504-6450
Joint Application to Conduct a
Centralized Prescription Handling Pharmacy Service
Pharmacies that plan to engage in central prescription handling in accordance with N.J.A.C. 13:39-4.19 must submit this
application to the Board of Pharmacy.
All of the pharmacies involved in the shared central handling must complete and jointly le this application. It must be lled in
completely, sworn to and mailed to the Board of Pharmacy.
Please remember to include with this application a completed service agreement signed by all of the involved parties.
Please print clearly with ink.
Pursuant to N.J.A.C. 13:39-4.19, the following pharmacies and/or corporations hereby make application for approval to conduct
centralized prescription handling and certify to the correctness of the following information:
1. ___________________________________________________________________________________________________
2. ___________________________________________________________________________________________________
Check box and attach a list if there are more than two pharmacies involved in this specic Central Prescription Handling
application and provide all of the required information for each additional pharmacy.
If participating pharmacies have different ownership - Complete Attachment “A” for each pharmacy that will be participating
in the centralized prescription handling. (Make as many copies as you need.) Corporations with more than one pharmacy
participating should submit documentation (a spreadsheet is preferred) that contains the following information: the name, address,
telephone number, and the license numbers (state and D.E.A.) of each participating pharmacy, as well as the function(s) to be
performed in the centralized prescription handling process.
If all participating pharmacies have a common owner - Complete one copy of Attachment “A” and submit documentation (a
spreadsheet is preferred) that contains the following information: the name, address, telephone number, and the license numbers
(state and D.E.A.) of each participating pharmacy, as well as the function(s) to be performed in the centralized prescription
handling process (i.e. intake, central processing, central ll and dispensing).
You will be notied by mail when your application has been approved by the Board.
Attachment “A”
Application to Conduct a
Centralized Prescription Handling Pharmacy Service
1. Complete the information below for Pharmacy #1:
(a) Name of pharmacy: _________________________________________________________________________________
(b) Street address of pharmacy: ___________________________________________________________________________
(c) City: _______________________________________ State: _____________________ ZIP code: _______________
(d) Telephone number: ____________________________
(include area code)
(e) Home state pharmacy license number: __________________________________________________
(f) New Jersey Board of Pharmacy license number: ___________________________________________
(g) Federal controlled substance (D.E.A.) registration number: __________________________________
(h) Name of Registered Pharmacist-in-Charge: _______________________________________________
(i) Select the functions in the centralized prescription handling process that this participant will perform:
Intake Central processing Central ll Dispensing
(j) Are the licenses of all the pharmacists and pharmacy technicians (if applicable) in good standing in each state in
which they are licensed? Yes No
If “No,” provide details:
2. Complete the information below for Pharmacy #2:
(a) Name of pharmacy: _________________________________________________________________________________
(b) Street address of pharmacy: ___________________________________________________________________________
(c) City: _______________________________________ State: _____________________ ZIP code: _______________
(d) Telephone number: ____________________________
(include area code)
(e) Home state pharmacy license number: __________________________________________________
(f) New Jersey Board of Pharmacy license number: ___________________________________________
(g) Federal controlled substance (D.E.A.) registration number: __________________________________
(h) Name of Registered Pharmacist-in-Charge: _______________________________________________
(i) Select the functions in the centralized prescription handling process that this participant will perform:
Intake Central processing Central ll Dispensing
(j) Are the licenses of all the pharmacists and pharmacy technicians (if applicable) in good standing in each state in
which they are licensed? Yes No
If “No,” provide details:
The afdavits on the next pages must be completed by the owner, or a partner, as listed on this application or, if the
pharmacy is owned by a corporation, by a principal ofcer.
3. Have you attached a copy of the contractual agreement as per N.J.A.C. 13:39-4.19(d)1? Yes No
If “No,” provide details:
Afdavit - Party #1
Must be sworn to before a notary public or other authorized ofcer.
I do solemnly swear or afrm that the answers and statements made in this form are true and correct to the best of my knowledge
and belief. I understand that any omissions, inaccuracies or failure to make full disclosures may be deemed sufcient to deny
or withdraw approval to function as a participant in a Central Prescription Handling Pharmacy Service. I understand that I am
responsible for ensuring that each pharmacist-in-charge of each pharmacy participating in the centralized prescription handling
process has been notied and has acknowledged that he/she is responsible for complying with N.J.A.C. 13:39-4.19, and for
conducting and managing the pharmacy so as to be in compliance with all applicable state and federal laws.
I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are
willfully false, I am subject to punishment.
____________________________________________________________________________________________
Name of Pharmacy (give exact legal title)
_____________________________________________________________ __________________________________________________________________
Title Print name
__________________________________________________________________
Authorized signature
Subscribed and sworn to me this ________
day of _____________________ , 20 _____
____________________________________
Name of Notary Public (please print)
____________________________________
Signature of Notary Public
If more than two (2) parties are participating in this agreement, attach additional afdavits as needed.
Afx seal here
Afdavit - Party #2
Must be sworn to before a notary public or other authorized ofcer.
I do solemnly swear or afrm that the answers and statements made in this form are true and correct to the best of my knowledge
and belief. I understand that any omissions, inaccuracies or failure to make full disclosures may be deemed sufcient to deny
or withdraw approval to function as a participant in a Central Prescription Handling Pharmacy Service. I understand that I am
responsible for ensuring that each pharmacist-in-charge of each pharmacy participating in the centralized prescription handling
process has been notied and has acknowledged that he/she is responsible for complying with N.J.A.C. 13:39-4.19, and for
conducting and managing the pharmacy so as to be in compliance with all applicable state and federal laws.
I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are
willfully false, I am subject to punishment.
____________________________________________________________________________________________
Name of Pharmacy (give exact legal title)
_____________________________________________________________ __________________________________________________________________
Title Print name
__________________________________________________________________
Authorized signature
Subscribed and sworn to me this ________
day of _____________________ , 20 _____
____________________________________
Name of Notary Public (please print)
____________________________________
Signature of Notary Public
If more than two (2) parties are participating in this agreement, attach additional afdavits as needed.
Afx seal here
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Centralized Prescription Handling Pharmacy Service Joint Application to (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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