Application - Maryland Board Of Physicians

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MARYLAND BOARD OF PHYSICIANS
PO Box 37217, Baltimore, MD 21297
410-764-4705 or 1-800-492-6836, ext 4705
APPLICATION FOR PHYSICIAN’S PERMIT TO DISPENSE PRESCRIPTION DRUGS
INSTRUCTIONS
FOR BANK USE ONLY
Review the FAQs to determine whether you need a dispensing permit.
Date:____/____/20___
Complete this form, read and initial each letter after the certification; and
sign and date the application.
Check number:_________
If prescriptions will be dispensed in more than one location, a copy of the
dispensing permit is required at each location.
Amount Paid:________
Permit is valid for 5 years from the date of issue.
Name Code:_________
Submit the completed, signed form with a check or money order for
$1,050.00* payable to the Maryland Board of Physicians. Mail to
A
ID: 32
PP
above address.
* Note: Fee increase effective July 1, 2013.
NOTE: Documentation of completed
Application for (check one) ______ Initial ______ Renewal
CEs must be submitted with Dispensing
Permit Renewal Application
If renewal, Permit # ____________ Expiration Date ______/______/______
1. Physician license number __________________
Email address:_____________________________
2. Physician name _____________________________________________________________________________________________
Last
First
Middle
3. Is the dispensing permit “in the public interest” as defined in Health Occupation Article (H.O.A.) § 12-102(a)(2) and
Code of Maryland Regulations (COMAR) 10.13.03.B? Please explain.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
4. Primary Practice address where drugs will be dispensed.
______________________________________________________________________________________
_______________
Facility Name and Street Address
City
State
Zip Code
Telephone #
5. Additional Practice address(es) where drugs will be dispensed.
______________________________________________________________________________________
_______________
Facility Name and Street Address
City
State
Zip Code
Telephone #
______________________________________________________________________________________
_______________
Facility Name and Street Address
City
State
Zip Code
Telephone #
______________________________________________________________________________________
_______________
Facility Name and Street Address
City
State
Zip Code
Telephone #
______________________________________________________________________________________
_______________
Facility Name and Street Address
City
State
Zip Code
Telephone #

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