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 ....
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How to fill out the NJ Exemption/Waiver Application_DSA online
Navigating the NJ Exemption/Waiver Application_DSA can be straightforward when guided correctly. This guide provides clear, step-by-step instructions to assist you in completing the application accurately and efficiently online.
Follow the steps to complete the NJ Exemption/Waiver Application_DSA online.
- Press the ‘Get Form’ button to access the application and open it for filling out.
- In the first section, fill in the name of the pharmacy clearly. Ensure accuracy as this will be validated.
- Next, provide the pharmacy permit number.
- Enter the complete pharmacy address, including street address, city, state, and ZIP code.
- Fill in the telephone number, including the area code, and the NPI number.
- Identify the pharmacist-in-charge by entering their full name.
- Indicate who is submitting the application by entering their name and title.
- Choose whether you are applying for an exemption or a waiver. Provide the reasoning based on the applicable conditions.
- If applying for a waiver, describe any financial hardship or good cause preventing electronic submission. You may attach additional documentation if necessary.
- Review the statement regarding the validity of the exemption or waiver. Ensure compliance with the reporting requirements.
- Sign and date the application to certify that all information is true to the best of your knowledge.
- Finally, save your changes, and you may choose to download, print, or share the completed form.
Complete your NJ Exemption/Waiver Application_DSA online today to ensure a smooth submission process.
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