Pharmacy Notification and Checklist for Closing/Selling/Discontinuation of Services in Iowa

This form is intended to assist pharmacies to provide the 30 day prior notification to the Board of the pharmacy's sale, closing, or discontinuation of services in Iowa and to provide a checklist for the pharmacy to ensure complete compliance.

Please refer to the complete rule for requirements for closing or sale of a pharmacy in 657 IAC 8.35(7).

Please refer to the complete rule for requirements for discontinuing services in Iowa in 657 IAC 19.2(5).

A pharmacy cannot execute a sale or closing of a pharmacy unless there is adequate time prior to the pharmacy's closing for delivery of the notification to the PIC, the Board, the DEA, and the pharmacy patients.

INSTATE PHARMACIES - If you are in possession of any of the following items please contact The Board of Pharmacy by email (pmp@iowa.gov) to make arrangements for them to be picked up as they are the property of the Iowa Board of Pharmacy:

Green "MedDrop" stainless steel medication disposal receptacle
Blue "MedDrop" stainless steel medication disposal receptacle
22 gallon cardboard receptacle liner for MedDrop systems
18 gallon Sharps "MedSafe" stainless steel medication disposal receptacle
38 gallon Sharps "MedSafe" stainless steel medication disposal receptacle
18 gallon cardboard inner liner for MedSafe systems
38 gallon cardboard inner liner for MedSafe systems
20 gallon cardboard "TakeAway" Environmental Return System for non-controlled substances

Pharmacy Name

Pharmacy Phone Number

Iowa Pharmacy License Number

Does the pharmacy have an active Iowa Controlled Substance Act Registration (CSA)?

Yes

Iowa CSA Registration Number

DEA Registration Number

Compliance Officer (Please indicate the compliance officer for your territory)

Is the pharmacy permanently closing or being sold? If nonresident pharmacy, discontinuing services in Iowa?

Closing

Selling

Discontinuing Services in Iowa

Date of Closing/Sale/Discontinuation of Services in Iowa (must be more than 30 days from today)

If the date indicated above is less than 30 days from today, please explain why the pharmacy did not timely file the notice to the Board.

A closing pharmacy or nonresident pharmacy discontinuing services in Iowa must ensure that all prescription drugs, prescription files, patient profiles, and controlled substance receipt and disbursement records are transferred to another Iowa licensed pharmacy that agrees to act as custodian of the records for at least two years (657 IAC 8.35(7))

Name of Iowa pharmacy where the pharmacy records are being transferred

Iowa Pharmacy License Number (where pharmacy records are being transferred)

Does the pharmacy where the records are being transferred have an active Iowa Controlled Substance Act Registration (CSA) and/or DEA Registration?

Yes

Iowa CSA Registration Number (where pharmacy records are being transferred)

DEA Registration Number. (where pharmacy records are being transferred)

Provide the date the PIC of the closing/selling pharmacy was notified (must be at least 40 days prior to the effective date of the sale or closing of the pharmacy, 657 IAC 8.35(7)"a")

If the date that the PIC was notified was less than 40 days from the effective date of the proposed sale or closing, please explain why they were not timely notified.

Provide the date that the PIC of the purchasing pharmacy was notified (must be at least 40 days prior to the effective date of the sale, 657 IAC 8.35(7)"a")

Has the DEA been notified of the closing or proposed sale of the pharmacy (657 IAC 8.35(7)"b")?

Yes

Provide the date that the DEA was notified or anticipated notification date

Refer to the DEA website for notification procedures and cancellation of 222 Forms and CSOS authorizations.

Patient Notification: Every patient with records of prescriptions filled by the closing/sold pharmacy within the past 18 months, must be notified by direct mail or personal delivery at least 30 days prior to the pharmacy closing date (657 IAC 8.35(7)"d").

Check the boxes to attest what information was provided in the notices sent to patients

The anticipated closing date of the closing/sale of the pharmacy

The identity of the pharmacy receiving the patient prescriptions and records

Directive to patients to, prior to closing, contact the closing pharmacy with any questions about their prescriptions and records

Directive to patients to, following record transfer, contact the pharmacy to which their records were transferred with any questions about their prescriptions and records

Provide the date that the patient notifications were sent

Provide the date that the public notice was posted at the pharmacy (pick-up locations, including drive-through lanes, store entry and exit doors, and at pharmacy prescription counters, 657 IAC 8.35(7)"d")

If either of the above notice dates were less than 30 days from the date that the pharmacy's closing or sale date, explain why patients were not timely notified.

Anticipated date that the inventory requirements for closing or sold pharmacy will be completed at the close of business, including transfer, destruction, and disposal of prescription drugs (657 IAC 8.35(7)"f")

I attest that, within 10 days of closing, the pharmacy will complete the following:

Return the pharmacy license certificate to the Iowa Board of Pharmacy

Return the CSA registration certificate to the Iowa Board of Pharmacy

Remove or cover signs identifying closed location as a pharmacy

Return DEA registration certificate and all unused DEA Forms 222 to the DEA

Cancel any active DEA CSOS authorization(s) for the closed pharmacy location

I attest that, within 10 days of the sale, the pharmacy will complete the following:

Return the pharmacy license certificate to the Iowa Board of Pharmacy

Return the CSA registration certificate to the Iowa Board of Pharmacy

Return DEA registration certificate and all unused DEA Forms 222 to the DEA

Cancel any active DEA CSOS authorization(s) for the closed pharmacy location

I attest that, within 10 days of discontinuing services in Iowa, the pharmacy will complete the following:

Return the pharmacy license certificate to the Iowa Board of Pharmacy

Return the CSA registration certificate to the Iowa Board of Pharmacy

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First Name

Last Name

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I hereby swear or affirm under penalty of perjury that the information provided in this application is true and correct. I understand that failure to provide complete and truthful information may constitute grounds for denial, revocation, or other disciplinary sanctions against the pharmacy's license. Information provided on this application may be disclosed pursuant to 657 IAC Chapter 14.