McKesson Medical Surgical Inc. Controlled Substance Customer Questionnaire and Declaration

Transcription

1 Date Questionnaire Completed: McKesson Account Number: McKesson Sales Representative Name (if known): McKesson Sales Representative Telephone Number (in known): I. Medical Practice/Clinic: General Information & Licensing a. Business Name: b. Address: c. Phone: Fax: d. Website address: e. Practitioner s Name (responsible for controlled substance purchases): f. Practitioner s Licenses: State: State: State: State Controlled Substances: DEA Registration: Practitioner s Licenses License Number Expiration Date II. Surgery Center, Facility or Pharmacy: General Information & Licensing a. Business Name: b. Address: June 2012 Page 1

2 c. Phone: Fax: d. Website address: e. Facility Licenses (Include all states in which licensed) State License Number Expiration Date III. Ownership/Business History a. Owner Information: Owner(s) name DBA (if applicable): Address: Phone: b. Ownership type: Sole Proprietor Corporation If so, State of Incorporation Partnership c. History. Please provide explanation for any Yes answers. i. Has any owner been convicted or charged with a felony or any other crime related to fraud/controlled substances? Yes No June 2012 Page 2

3 ii. Has the DEA registration ever been suspended, revoked or subject to a past or pending disciplinary action? Yes No iii. Has a state license ever been suspended, revoked or subject to a past or pending disciplinary action? Yes No iv. Has any previous wholesaler ceased shipping or restricted purchases of controlled substances? Yes No d. Do you conduct criminal background checks on all employees involved in controlled substance operations? Yes No IV. Business Information a. Business classification (please check all that apply) College/ University Dentist Family Practice Distributor/ Wholesaler Federal Government Facility Orthopedic Practice Pain Management Practice/Clinic Pharmacy Physician State Government Facility Reseller Surgery Center Veterinarian Weight Loss Clinic Other Please Describe: June 2012 Page 3

4 b. List wholesale distributors used in lasts 24 months and indicate whether they are a primary or secondary source of controlled substances: Wholesaler Name Primary Source Secondary Source c. Please describe the reason for becoming a McKesson customer? d. If a physician practice/clinic, how is business received? (Please list percent) Walk-in: % Appointment: % e. Is practice/clinic located within a retail environment? Yes No f. What is the average distance that your patients travel to reach your facility? Average distance in miles: g. What is the longest distance for a patient to travel? Distance in miles: h. What is the average number of patients per day per doctor? i. Describe the services offered by the practice/clinic: j. Does the practice/clinic dispense controlled substance for the patient to take home? Yes No k. Does the practice/clinic administer controlled substances to patients for in-office procedures? Yes No l. Does the practice/clinic provide minimum doses of controlled substances as a convenience until the patient can fill a prescription? Yes No June 2012 Page 4

5 m. Do you treat weight loss or have a weight loss program? Yes No n. Do you treat drug addiction rehabilitation? Yes No If yes, attach Substance Abuse Clinic registration and list of staff members who are authorized to sign 222 forms: V. Purchasing Information a. Total estimated monthly purchases of all items (i.e. Rx Drugs, Controlled Substances, Devices, OTC Products, and Supplies) $ b. Total estimated monthly Rx drug purchases (including controlled substances) $ c. Purchase breakdown: Rx Drugs: % Controlled Substances: % All Other Items: % d. Number of prescriptions filled per day / per month e. Method of payment by your patients/customers: Private insurance: % Medicare/Medicaid: % Cash: % Credit Card: % Other: % VI. Controlled Substance Purchases a. Estimate dose units (tablets/capsules) dispensed per month for each of the following Controlled Substances Controlled Substance Tablets/Capsules Dispensed Per Month Alprazolam Quantity [ ] Dispensed Per Month Carisoprodol Quantity [ ] Dispensed Per Month Hydrocodone Quantity [ ] Dispensed Per Month Methadone Quantity [ ] Dispensed Per Month Oxycodone Quantity [ ] Dispensed Per Month Phentermine Quantity [ ] Dispensed Per Month Suboxone Quantity [ ] Dispensed Per Month June 2012 Page 5

6 b. Estimate dose units (tablets/capsules) administered per month for each of the following Controlled Substances. Controlled Substance Tablets/Capsules Administered Per Month Alprazolam Quantity [ ] Administered Per Month Carisoprodol Quantity [ ] Administered Per Month Hydrocodone Quantity [ ] Administered Per Month Methadone Quantity [ ] Administered Per Month Oxycodone Quantity [ ] Administered Per Month Phentermine Quantity [ ] Administered Per Month Suboxone Quantity [ ] Administered Per Month c. List other controlled substances that your business dispenses: d. List other controlled substances that your business administers: VII. Declaration Customer certifies that it fully complies with all applicable federal and state laws and regulations regarding the dispensing of controlled substances. Customer further certifies that it only dispenses controlled substances to patients pursuant to a legitimate prescription issued in the course of an established doctor-patient relationship and only for a legitimate medical purpose. Customer will not knowingly dispense controlled substances for prescriptions that have been received via the internet, mail-order, or other non-walk-in customer where it has reason to believe that the prescription was issued without a legitimate medical purpose. Customer agrees to notify McKesson immediately if the Practitioner/License holder responsible for controlled substances purchases leaves the practice. Customer certifies that it has made sufficient inquiry to be able to make this declaration truthfully, accurately and without material omissions and that the above is true and correct to the best of its knowledge and belief. Signature: (Practitioner/License Holder Responsible for Controlled Substance Purchases) Printed Name of Practitioner License Holder: Date: June 2012 Page 6

7 VIII. McKesson Review McKesson Regulatory Signature: Name (Printed): Title: Date: Please return this document via fax, , or mail to the Regulatory License Team Manager. McKesson Medical-Surgical Regulatory License Team Manager 8741 Landmark Road P.O. Box Richmond, VA (804) Fax June 2012 Page 7