Section 1 of 1 in this document

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 Board's rule for voluntary license cancellation at 481 IAC 551.2(15).

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 the item(s) 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

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.

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 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 given written notice, which may include electronic communication, at least 30 days prior to the pharmacy closing date [481 IAC 551.2(15)(a)(2)]

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 the date indicated above is less than 30 days from the pharmacy's closing or sale date, explain why patients were not timely notified.

Anticipated date that the inventory requirements will be completed at the close of business, including transfer, destruction, and disposal of prescription drugs [481 IAC 553.5(3)]

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

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

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 481 IAC Chapter 5.

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

Pharmacy Address

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

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

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

Address of Iowa pharmacy where the 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?

Name of the PIC of the purchasing pharmacy

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")?

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

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

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")

Anticipated date that the inventory requirements will be completed at the close of business, including transfer, destruction, and disposal of prescription drugs [481 IAC 553.5(3)]

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

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

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

Sign Here