Get La Form 53-s 2019

This guide aims to assist users in successfully completing the LA Form 53-S for the application of a Louisiana Hospital Off-Site Satellite Pharmacy Permit online. By following the step-by-step instructions provided, you can ensure that your application is filled out accurately and submitted without delay.

Follow the steps to complete your application online.

1. Click ‘Get Form’ button to obtain the form and open it in the document editor.
2. Begin by selecting the type of permit requested in Section 1. Choose the appropriate option for 'Hospital Off-Site Satellite' and note the application fee of $175.
3. In Section 2, indicate the reason for your application. Select either 'New Pharmacy Permit' or 'Change of Ownership' and enter the anticipated date of opening.
4. Provide the required provider pharmacy information in Section 3. This includes the name, physical address, and license details for the hospital pharmacy that supervises the off-site satellite pharmacy.
5. Fill out Section 4 with the designated contact person’s information including their name, company, address, telephone, and email.
6. In Section 5, ensure that a corporate resolution specifying the authority for the Pharmacist-in-Charge is included in your application package.
7. Complete Section 6 with the satellite pharmacy's name, address, and contact information. Include the LDH License number for the facility.
8. In Section 7, indicate whether the pharmacy will perform any special services by checking the appropriate boxes for each service offered.
9. In Section 8, confirm that the required attachments for the LDH Licenses for both the Hospital Location Housing Provider and Satellite Pharmacy are included.
10. For Section 9, if applicable, indicate the need for a Louisiana Controlled Dangerous Substance License and DEA Registration.
11. In Section 10, the Pharmacist-in-Charge must attest to the knowledge and agreement of all statements by providing their printed name and signature.
12. After completing all sections, review your application thoroughly to ensure all information is accurate. You can then save changes, download, print, or share the completed form as needed.

Complete your application for the Louisiana Hospital Off-Site Satellite Pharmacy Permit online today.