Get La Form 53-s 2021-2025

This guide provides clear instructions for completing the LA Form 53-S, the application for a Louisiana Hospital Off-Site Satellite Pharmacy Permit. Follow the steps outlined below to ensure accurate submission of your application online.

Follow the steps to fill out the LA Form 53-S online effectively.

1. Press the 'Get Form' button to access the application form and launch it in the online editor.
2. In Section 1, select the type of permit you are requesting. Check the box for 'Hospital Off-Site Satellite' and note the fee of $175.
3. Complete Section 2 by indicating whether you are applying for a new pharmacy permit or changing ownership of an existing permit. Enter the anticipated date of opening or the permit number if applicable.
4. Provide information about the provider pharmacy in Section 3, including the name, physical address, city, state, ZIP code, pharmacy permit number, and the Pharmacist-in-Charge's name.
5. Enter the designated contact person's details in Section 4, including their name, company, mailing address, city, state, ZIP code, and contact information.
6. In Section 5, ensure that a corporate resolution is attached that grants authority to the Pharmacist-in-Charge to execute the application.
7. Fill out Section 6 with the satellite pharmacy details, repeating the same information required in Section 3.
8. In Section 7, indicate whether the satellite pharmacy will provide any special services by checking the relevant boxes.
9. Complete Section 8 by confirming whether you have attached the required LDH licenses for both the provider and satellite pharmacies.
10. Address the requirements for controlled dangerous substances in Section 9, noting that a Louisiana Controlled Dangerous Substance License and DEA Registration may be necessary.
11. Review the attestations in Section 10 and ensure that the Pharmacist-in-Charge prints their name and signs the application to affirm compliance.
12. After filling out all sections and validating the information, save your changes, and download, print, or share the form as needed.

Start completing your LA Form 53-S online today to ensure timely processing of your application.