Florida

Board

of

Pharmacy

If you answer “yes” to any of the disciplinary history questions on the application, Please provide a certified copy of document(s) relative to any disciplinary action taken against any license. The documents must come from the agency that took the disciplinary action and must be certified by that agency.

In addition, include detailed description of the circumstances surrounding your disciplinary action and a thorough description of the rehabilitative changes in your lifestyle since the time of the disciplinary action which would enable you to avoid future occurrences. It would be helpful to include factors in your life, which you feel may have contributed to your disciplinary action, what you have learned about yourself since that time, and the changes you have made that support your rehabilitation.

The Board of Pharmacy has created guidelines for specific actions to be cleared in the board office; however, the staff cannot make determinations in advance as laws and rules do change over time.

The Board of Pharmacy has created guidelines for specific offenses to be cleared in the board office; however, the staff cannot make determinations in advance as laws and rules do change over time. Violent crimes and repeat offenders are required to be presented to the Board of Pharmacy for review. Evidence of rehabilitation is important to the Board when making licensure decisions.

Applicants with prior criminal convictions are required to submit the following documentation to the Board:

Final Dispositions/Arrest Records – Final disposition records for offenses can be obtained at the clerk of the court in the arresting jurisdiction. If the records are not available, you must have a letter on court letterhead sent from the Clerk of the Court attesting to their unavailability.

Completion of Probation/Parole/Sanctions – Probation and financial sanction records for offenses can be obtained at the clerk of the court in the arresting jurisdiction. Parole records for offenses can be obtained from the Department of Corrections or at the clerk of the court in the arresting jurisdiction. If the records are not available, you must have a letter on court letterhead sent from the clerk of the court attesting to their unavailability.

Self Explanation – Applicants who have listed offenses on the application must submit a letter in their own words describing the circumstances of the offense.

Failure to submit fingerprints will delay your application. All owners, officers and prescription department managers are required to submit a set of fingerprints unless the corporation is exempt under the Section 465.022, Florida Statutes for corporations having more than $100 million of business taxable assets in this state. These corporations are only required to have the prescription department manager or consultant of record to submit fingerprints. The statute allows the prescription department manager for a corporation having more than $100 million of business taxable assets in this state to submit results from AHCA if the results were also available to the Department and are within one year of the receipt date of the application. If the manager prints were submitted to DOH within one year of the date of the application they are not required to submit them over.

The Department of Health accepts electronic fingerprinting service offered by Livescan device vendors approved by the Florida Department of Law Enforcement and listed on their site. Livescan Service Providers

You must provide accurate demographic information at the time your fingerprints are taken, including your Social Security number. The Department will not be able to process a submission that does not include your Social Security number.

You must provide the correct ORI number. The ORI number for the pharmacy profession is EDOH4680Z

IMPORTANT NOTICE: The department or board shall deny an application for a pharmacy permit if the applicant or an affiliated person, partner, officer, director, or prescription department manager or consultant pharmacist of record of the applicant:

(a) Has been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under Chapter 409, Chapter 817, or Chapter 893, Florida Statutes (F.S.), or a similar felony offense committed in another state or jurisdiction, since July 1, 2009.

(b) Has been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under 21 U.S.C. ss. 801-970 or 42 U.S.C. ss. 1395-1396 since July 1, 2009.

(c) Has been terminated for cause from the Florida Medicaid program pursuant to s. 409.913, F.S., unless the applicant has been in good standing with the Florida Medicaid program for the most recent 5-year period.

(d) Has been terminated for cause, pursuant to the appeals procedures established by the state, from any other state Medicaid program, unless the applicant has been in good standing with a state Medicaid program for the most recent 5-year period and the termination occurred at least 20 years before the date of the application.

(e) Has obtained a permit by misrepresentation or fraud.

(f) Has attempted to procure, or has procured, a permit for any other person by making, or causing to be made, any false representation.

(g) Has been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a crime in any jurisdiction which relates to the practice of, or the ability to practice, the profession of pharmacy.

(h) Has been convicted of, or entered a plea of guilty or nolo contenedre to, regardless of adjudication, a crime in any jurisdiction which relates to health care fraud.

(i) Is currently listed on the United States Department of Health and Human Services Office of Inspector General’s List of Excluded Individuals and Entities.

(j) Has dispensed any medicinal drug based upon a communication that purports to be a prescription as defined by s. 465.003(14) or s. 893.02, F.S., when the pharmacist knows or has reason to believe that the purported prescription is not based upon a valid practitioner-patient relationship that includes a documented patient evaluation, including history and a physical examination adequate to establish the diagnosis for which any drug is prescribed and any other requirement established by board rule under Chapter 458, Chapter 459, Chapter 461, Chapter 463, Chapter 464, or Chapter 466, F.S.

If applicable, please provide documentation to the Florida Board of Pharmacy.