Get NJ Exemption/Waiver Application_DSA

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 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 . only to inpatients in a hospital long-term care or other facility in which the residents are provided with 24-hour nursing care. 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. New 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 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 . 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 NJPMP dca.lps.