Applications & Forms

NOTE: SOCIAL SECURITY NUMBERS You are required to provide your social security number as part of each application pursuant to 42 U.S.C. § 666(a)(13) and K.S.A. 74-148. Your social security will be used for identifying you, reporting to the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank and will be provided to the Kansas Department of Revenue pursuant to K.S.A. 74-139 and Kansas Social Rehabilitation Services pursuant to K.S.A. 74-148 and K.S.A. 39-758.

Licensing and Registration Forms

Business Applications and Forms

Ambulance/Emergency Medical Service Application (also for change location and ownership)

Analytical Labratory Application (also for change in location and ownership)

Distributor of Prescription Drugs and/or Controlled Substances (also includes devices sold at wholesale-not those shipped directly to the patient)(also for change in location and ownership)

Durable Medical Equipment & Devices

Health Department and Private Not-For-Profit Family Planning Clinic (also for change in PIC, location, and ownership)

Indigent Care Clinic (also for change in PIC, location, and ownership)

Institutional Drug Room Registration Application ( also for change in PIC, location, and ownership)

Nonprescription Drug Distributor/Wholesaler Registration Application (also for change in location and ownership)

NonResident Pharmacy Registration Application (also for change in PIC, location, and ownership)

Pharmacy Registration Application --Pharmacies located in Kansas (also for change in PIC, location, and ownership)

Manufacturer Registration Application (out of state manufacturors will be licensed as a distributor) (also for change in location and ownership)

Research and Teaching Institution Application (also for change in location and ownership)

Retail Dealer Application (also for change in location and ownership)

Sample Distribution Permit Application

Individual Applications and Forms

Intern Application

Pharmacist Licensure Application (To obtain the registration form for the MPJE, go to the NABP website.)

Application for Disability Accomodation

Technician Application

Donated Medication Forms

Cancer Drug Repository Forms

Cancer Drug Repository Donation, Transfer & Destruction Record

Cancer Drug Repository Notice of Participation or Withdrawal Form

Cancer Drug Repository Patient Consent Form

Unused Medication Program Forms

Instructions for Utilization of Unused Medication Program

Participation Form-Donating Entities

Participation Form-Clinics & Qualifying Centers

Adult Care Home- Unused Medications Manifest and Declaration

Mail Order Pharmacy & Medical Care Facility- Unused Medications Manifest and Declaration

Unused Medications Manifest

Indigent Care Clinic Application (**You must be registered with the Board of Pharmacy as an indigent care clinic before you can participate in the program.**)

Statutes & Regulations

Miscellaneous Forms

Continuous Quality Improvement Forms

CQI Meeting Sample Report

Transer of Controlled Substances

Transfer of Controlled Substances Form

Miscellaneous Licensing/Registration Forms

Duplicate Wall Certificate Application (FOR PHARMACISTS ONLY)

Duplicate Pocket Card Application

Internship Affidavit

Internship Affidavit page 2

Technicians Listing

Legal & Disciplinary Forms

Complaint Form

Risk Management Report Form (For Medical Care Facilities Only)

DEA 106 Form--Theft or Loss of Controlled Substances

Information Request/Open Records Request Form

Open Records Request Form (To view available disciplinary actions, go to the disciplinary actions page.)

*All of these files are in .pdf format. If you haven't already downloaded Adobe Reader® on your computer to open up .pdf documents, please visit the Adobe Acrobat® site.