Get Sd Doh Change Notification Form For Resident And Nonresident Pharmacies

Filling out the SD DoH Change Notification Form is essential for pharmacies to report changes in their details to the South Dakota Board of Pharmacy. This guide provides a structured approach to help you complete the form accurately and efficiently online.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in your browser.
2. Enter the name of the pharmacy in the 'Pharmacy Name' field, along with the associated license number in the format provided.
3. Fill in the 'Effective Date of Change' to indicate when the changes will take effect.
4. If applicable, complete the 'Name Change' section. Resident entities only need to fill out the form, while nonresident entities must include a copy of their home state license reflecting the new name.
5. Provide the 'Current Legal Name' and 'New Legal Name' where prompted, along with 'Current DBA Name' and 'New DBA Name' if applicable.
6. For a 'Location Change,' resident entities complete the form only. Nonresident entities need to attach their home state license reflecting the new address and a copy of the new location inspection report. If no inspection occurred, include an explanation.
7. Fill out the 'Current Address' and 'New Address' fields, ensuring that the city, state, and ZIP code are accurate.
8. If applicable, indicate if the pharmacy is closing or surrendering its license by completing the corresponding section and signing accordingly.
9. Ensure that a representative or person in charge (PIC) signs the form. Include their printed name, title, contact number, and email.
10. Review all entered information for accuracy. Once satisfied, save changes, download, and print the form if necessary.
11. Email the completed form and any required documents in PDF format to the Board at the provided email address.

Ensure your pharmacy is compliant by submitting the change notification form online today.