Get Ks Form Ba-11 2022-2025

Filling out the KS Form BA-11 is an essential step for registering county health or family planning services in Kansas. This guide provides a clear and structured approach to help users navigate the form efficiently and effectively.

Follow the steps to complete the KS Form BA-11 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by indicating whether this is a new application or a change. Select the appropriate option and provide the previous registration number if applicable.
3. Specify the facility type by selecting from the provided options, such as Health Department, Private Non-Profit Family Planning Clinic, or others listed.
4. Fill in the owner information, including the name, address, phone number, email, and ownership type. If applicable, provide the Social Security Number (SSN) or Federal Employer Identification Number (FEIN).
5. Complete the department or clinic information section. This includes the name of the clinic, the hours per week a pharmacist is on duty, and the physical address.
6. Enter the designated representative's information, ensuring to provide their name, title, address, and contact details.
7. Designate where all formal correspondence should be sent by selecting the appropriate option for either the owner, physical location, or designated representative.
8. List the pharmacist-in-charge’s name, license number, hours per week they work at the facility, and contact details.
9. Enumerate all licensed pharmacists working at the facility. You may need to attach additional pages for more names and license numbers.
10. Review the PIC certification and ensure to sign and date the form. This section confirms the acceptance of responsibility for compliance with relevant laws.
11. Once all sections are completed, save your changes, and then you may choose to download, print, or share the completed form as required.

Start completing your KS Form BA-11 online now to ensure a smooth registration process.