Applications and Forms

 

NOTE: SOCIAL SECURITY NUMBERS You are required to provide your social security number as part of each application pursuant to 42 U.S.C. § 666(a)(13) and K.S.A. 74-148. Your social security will be used for identifying you, reporting to the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank and will be provided to the Kansas Department of Revenue pursuant to K.S.A. 74-139 and Kansas Social Rehabilitation Services pursuant to K.S.A. 74-148 and K.S.A. 39-758.

*All of these files are in .pdf format. If you haven't already downloaded Adobe Reader® on your computer to open up .pdf documents, please visit the Adobe Acrobat® site.

***Many applications were updated in 2008, so please use the links below to obtain the most current license applications.***

 

A-F
Ambulance/Emergency Medical Service Application (8k) (also for change location and ownership)
Analytical Labratory Application (8k) K.A.R. 68-20-9; 68-20-10 (also for change in location and ownership)
Complaint Form (8k)
Cancer Drug Repository Donation, Transfer & Destruction Record
Cancer Drug Repository Notice of Participation or Withdrawal Form
Cancer Drug Repository Patient Consent Form
Distributor of Prescription Drugs and/or Controlled Substances (also includes devices sold at wholesale-not those shipped directly to the patient)(12k) K.S.A. 65-1645; 65-1655 K.A.R. 68- 14-1; 68-14-2; 68-14-3; 68-14-4; 68-14-5; 68-14-6; 68-14-7; 68-14-8 (also for change in location and ownership)
Duplicate Wall Certificate Application (FOR PHARMACISTS ONLY) (4k)
Duplicate Pocket Card Application

Durable Medical Equipment & Devices

G-L
Health Department and Private Not-For-Profit Family Planning Clinic (8k) K.S.A. 65-1648 K.A.R. 68-7-18 (also for change in PIC, location, and ownership)
Indigent Care Clinic (also for change in PIC, location, and ownership)
Institutional Drug Room Registration Application (8k) K.S.A. 65-1626(o)(1); 65-1629; 65-1637a; 65-1643 ( also for change in PIC, location, and ownership)
Internship Affidavit (8k)
Internship Affidavit page 2 (8k)
Intern Application

M-Q
Nonprescription Drug Distributor/Wholesaler Registration Application(12k) K.A.R. 68-15-1; 68-15-2; 68-15-4 (also for change in location and ownership)
NonResident Pharmacy Registration Application (16k) K.S.A. 65-1657 K.A.R. 68-7-12a (also for change in PIC, location, and ownership)
Open Records Request Form (To view available disciplinary actions, go to the disciplinary actions page.)
Pharmacist Licensure Application (To obtain the registration form for the MPJE, go to the NABP website.)
Pharmacy Registration Application --Pharmacies in Kansas--(16k) K.S.A. 65-1626(r) K.A.R. 68-1-2a; 68-1-8; 68-7-13; 68-2-9; 68-2- 10 (also for change in PIC, location, and ownership)
Manufacturer Registration Application (12k) (also for change in location and ownership)

R-Z
Research and Teaching Institution Application (12k) (also for change in location and ownership)
Retail Dealer Application (8k) (also for change in location and ownership)
Retail Dealer Self Inspection Form
Risk Management Complaint Form (For Medical Care Facilities Only)
Sample Distribution Permit Application (4k)
Technicians Listing (8k)
Technicians Application and Instructions
Utilization of Unused Medications Program Forms

DEA 106 Form--Theft of Loss of Controlled Substances