Application - Maryland Board Of Physicians Page 2
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4Please read and initial the space on the left of each lettered paragraph as acknowledgment.
I HEREBY CERTIFY THAT:
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A. I am thoroughly familiar with the statutes and regulations which govern physician dispensing of prescription
drugs, including (H.O.A.)§§12-102, 12-505, and 12-604, and COMAR 10.13.01, 10.19.03.04, 10.19.03.05,
and 10.19.03.07.
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B. I have read and understood the enclosed information sheet for physicians who are dispensing drugs.
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C. I will comply with the dispensing requirements set forth in COMAR 10.13.01, Regulations .01--.05 and the
above-referenced statutes and regulations.
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D. I understand that I must follow the requirements listed in COMAR 10.13.01.04 regarding dispensing, label-
ing, record keeping, and patient notifications in order to receive and maintain a permit to dispense. Failure to
comply with these requirements or other conditions included in the laws and regulations may be considered a
violation of H.O.A. §14-404(a)(28).
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E. I will annually report to the Board on my anniversary date, whether I have personally prepared and dispensed
prescription drugs within the previous year.
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F. With the exceptions below, I have completed ten continuing education (CE) credits over a 5 year period re-
lating to the preparing and dispensing of prescription drugs, offered by the Accreditation Council for Phar-
macy Education (ACPE) or as approved by the Secretary of the Department of Health and Mental Hygiene.
Documentation of CE credits is attached to this application. The required continuing education credits will
be phased in as follows:
a.
For permits that expire in 2014, the physician shall complete two continuing education credits;
b.
For permits that expire in 2015, the physician shall complete four continuing education credits;
c.
For permits that expire in 2016, the physician shall complete six continuing education credits;
d.
For permits that expire in 2017, the physician shall complete eight continuing education credits;
e.
For permits that expire in 2018, the physician shall complete ten continuing education credits.
I understand that I must submit documentation of completed CE’s with my Drug
Dispensing Permit Renewal Application
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G. I do not have a substantial financial interest in a pharmacy.
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H. I do not direct patients to a single pharmacist or pharmacy in accordance with H.O.A. §12-403(b)(8).
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I.
I personally prepare and dispense as defined in H.O.A. § 12-102(3)(i) and (ii).
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J.
I ensure that signs are posted at each dispensing location (H.O.A. §12-102(2)(i)(4)).
K. I will allow the Division of Drug Control to enter and inspect the dispensing office at all reasonable hours
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and in accordance with H.O.A.§12-102.1.
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Physician’s Signature
Date
REV: 07/2013
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