Exemption/waiver Application - New Jersey Office Of The Attorney General
Download a blank fillable Exemption/waiver Application - New Jersey Office Of The Attorney General in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Exemption/waiver Application - New Jersey Office Of The Attorney General with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1New Jersey Office of the Attorney General
Division of Consumer Affairs
Prescription Monitoring Program
124 Halsey Street, 7th Floor, P.O. Box 45027
Newark, New Jersey 07101
Exemption/Waiver Application
Please print CLEARLY. You must answer all of the questions on this form.
Name of pharmacy: _____________________________________________________________________________
Pharmacy permit number: ________________________________________________________________________
Pharmacy address: _____________________________________________________________________________
Street Address
City
State
ZIP Code
Telephone number: ____________________________ NPI number: ____________________________________
(include area code)
Name of pharmacist-in-charge: ___________________________________________________________________
Name and title of person submitting application: ______________________________________________________
Application for Exemption
Based on the following, I request an exemption from the reporting requirements of the Prescription Monitoring Program:
The pharmacy does not dispense Schedule II, III, IV or V controlled dangerous substances or human growth
hormone.
The pharmacy dispenses Schedule II, III, IV and V controlled dangerous substances or human growth hormone
only to inpatients in a hospital, long-term care or other facility in which the residents are provided with 24-hour
nursing care.
Application for Waiver
Based on the following, I request a waiver from the electronic submission requirements of the Prescription Monitoring Program:
Financial hardship or other good cause prevents the pharmacy from electronically submitting required
prescription information to the Division. Please provide a brief description below, or submit a separate document,
detailing the reason(s) you are unable to comply with the electronic submission requirement, and describe
how you will submit the required information.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Unless otherwise limited by the Division, an exemption or waiver granted by the Division shall be valid for one
year from the date it is issued. If during this one-year period, the conditions which necessitated the exemption
or waiver no longer exist, the pharmacy shall notify the Division, and the exemption or waiver shall become
void. If the reasons necessitating the exemption or waiver persist beyond the one-year period, the pharmacy
shall apply to the Division for a renewal of the exemption or waiver.
I certify that all of the information provided in this Exemption/Waiver Application is true to the best of my knowledge,
information and belief, and acknowledge that failure to provide accurate and true information may result in disciplinary
action or the imposition of civil penalties.
____________________________________________
__________________________________
Signature of Applicant
Date
Mail this form to the Prescription Monitoring Program at P.O. Box 45027, Newark, New Jersey 07101 or submit it
electronically at
ADVERTISEMENT
0 votes
Related Articles
Related forms
New Jersey Office Of The Attorney General - New Jersey Division Of Consumer Affairs - Complaint
Legal
Application Form For Amusement Games License N.j.s.a. 5:8-100 Et Seq - New Jersey Office Of The Attorney General
Legal
Initial Application Form For Bingo/raffle Equipment Providers, Instant Raffle Equipment Distributors/manufacturers, And Casino Night/armchair Race Equipment Providers - New Jersey Office Of The Attorney General
Legal
Renewal Application For A Compensated Casino Night Employee (annually) Form - New Jersey Office Of The Attorney General
Legal
Form Sr-2 - Campaign Report Of Charitable Solicitation By An Independent Paid Fund Raiser Or Fund-raising Counsel - New Jersey Office Of The Attorney General
Legal
Related Categories
Parent category: Legal