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OHIO STATE BOARD OF PHARMACY

77 South High Street, Room 1702 Columbus, OH 43215-6126


-Equal Opportunity Employer and Service Provider-

TEL: 614-466-4143 E-MAIL: exec@bop.ohio.gov FAX: 614-752-4836 TTY/TDD: Use the Ohio Relay Service: 1-800-750-0750 URL: http://www.pharmacy.ohio.gov

REQUEST FOR BOARD APPROVAL AS PICK-UP STATION (pursuant to OAC 4729-5-10)


Pharmacy Name Address TDDD #

02
TDDD # (or why exempt) MUST COMPLETE

Pick Up Station Name - attach list if more than one

Address

Delivering dispensed patient specific prescriptions Accepting hard copy prescriptions


to pick up station [4729-5-10(B)]
[4729-5-10(A)]

DESCRIPTION OF ACTIVITY (include narrative with specifics (what drugs, how you comply) on back of this form):

I attest that I have read OAC 4729-5-10, meet and will comply with the requirements of this rule as set forth. The narrative provided is an accurate reflection of the activity for which we seek approval.

Print/type name of Responsible Person Pharmacy

Print/type name of Responsible Person Pick up station

_ Signature of Responsible Person Pharmacy Signature of Responsible Person Pick up station

_ Email of Responsible Person Pharmacy Email of Responsible Person Pick up station

_ Phone# of Responsible Person Pharmacy Phone# of Responsible Person Pick up station

RPh license #

Professional license #

COMPLETED FORM & NARRATIVE MAY BE SCANNED AND EMAILED, OR FAXED, OR POSTAL MAILED TO THE CONTACT INFORMATION IN ABOVE LETTERHEAD
Board Office Use Only: Approved Denied Signature:

Date:
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PRESCRIPTION PICK-UP STATION


Rule 4729-5-10 [update effective 01/01/2009]

(A) No pharmacist shall accept prescriptions obtained from a place which offers, in any manner, its services as a "pick-up station" or intermediary for the purpose of having prescriptions filled unless such place is a pharmacy as defined in section 4729.01 of the Revised Code, has received board approval to function in such a manner, and all of the following apply: (1) (2) (3) (4) The site is appropriately licensed pursuant to Chapter 4729. of the Revised Code; The receipt, storage, control, and distribution of prescriptions are in the full and actual charge of a pharmacist licensed pursuant to Chapter 4729. Of the Revised Code; An appropriate recordkeeping system is in place that will provide accountability for proper receipt, delivery, and return of all prescriptions; There is a documented method in place to ensure compliance with rule 4729-5-22 of the Administrative Code.

(B) No pharmacist shall dispense dangerous drugs to a place which offers, in any manner, its services as a "pick-up station" or intermediary for the purpose of having prescriptions filled or delivered unless such place is a pharmacy as defined in section 4729.01 of the Revised Code, has received board approval to function in such a manner, and paragraphs (B)(1) to (B)(4) of this rule apply or, if not a pharmacy, unless all of the following apply: (1) (2) The site is appropriately licensed pursuant to Chapter 4729. of the Revised Code. The receipt, storage, control, and distribution of prescriptions or drugs are in the full and actual charge of a health care professional licensed pursuant to Chapter 4715., 4723., 4729., 4730., 4731., or 4741. of the Revised Code. An appropriate recordkeeping system is in place that will provide accountability for proper receipt, delivery, and return of all prescription medications. There is a documented method in place to ensure compliance with rule 4729-5-22 of the Administrative Code. The state board of pharmacy has approved the site for such activity due to clear and convincing evidence that delivery of prescription medication directly to the patient would result in: (a) (b) Danger to public health or safety, or Danger to the patient without increased involvement by a health care professional in the patients drug therapy.

(3) (4) (5)

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