OH PHA-0600 2011 free printable template

TERMINAL DISTRIBUTOR OF DANGEROUS DRUGS WITH A PAIN MANAGEMENT CLINIC CLASSIFICATION INSTRUCTIONS SUBMIT COMPLETED COPY OF BOTH FORM # 0600 & FORM # 0601 WITH ORIGINAL SIGNATURES TO THE BOARD OFFICE

Indicate whether this application is for a form # 0600 or FORM # 0601. 3. If form # 0600 is submitted, submit a valid and current drug liability insurance policy with the application. 4. Identify the location where the facility is to be located. 5. State your full legal name and address 6. Identify the purpose for which the application is authorized: The purpose for which the dangerous drug product is to be provided by this dangerous drug distributor or a designee. If no purpose is stated, the application was not filed timely. 7. Indicate the date the application was filed. 8. Name and address of the applicant/distributor or his/her agent 9. Name and address of the agent or his/her agent responsible for filing the application. 10. If no agent is named, the applicant/distributor is acting as agent, and no information is required. 11. Indicate the number and expiration date of the prescription drug product authorization (PDA) to be authorized to be distributed by applicant. 12. Indicate the number of days before applicant is no longer authorized to distribute the specified dangerous drug product that he/she is to continue to receive such PDA. 13. Indicate the identity of the manufacturer/supplier of the lethal drug product to be approved for use by respondent. 14. Indicate the quantity of the lethal drug product authorized to be distributed and the manner of administration. 15. Indicate the dosage units or equivalent thereof for which the applicant/distributor is authorized to distribute lethal drug product. 16. Indicate the method to be used within the United States in administering deadly drug product. 17. Sign the application under oath. 18. If this application is change to a current license, obtain from the Attorney General, Attorney General's agent, Attorney General's clerk, the Chief State's Attorney, the Secretary of State, and the Board of Law Examiners, all additional information and documents required to complete this application. If applicant is a corporation, partnership, other business entity, or other organization, furnish complete information of ownership and control (including all officers, directors, stockholders, and partners). This registration will not be issued until all information required by the Board of Law Examiners is received. 19. Complete the form # 0601. 20. Sign the application and date it under oath. 21. The application shall be mailed to Commissioner, Department of Consumer Protection, Division of Health Care, P.O.

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