Kansas Board of Pharmacy
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The Board will only accept current typed versions of Board of Pharmacy forms. Old forms or handwritten forms will be returned (with payment) directly to the sender without processing. To ensure the most recent version, check the "Revised" date in the bottom right corner of each form.
On this page you'll find all Board of Pharmacy forms that are currently available online. Links on other web pages may direct you to these forms. Use the descriptions to find the right forms, which are available in pdf format and able to be electronically filled and signed online for submission to the Board office. Make sure you have included all fees and supporting documentation.
Applications for Pharmacists, Interns, and Technicians
Form # | Form Name | Revision Date |
---|---|---|
LA-01R | LA-01R Pharmacist by Reciprocity-Transfer | 04/2024 |
LA-01E | Pharmacist by Exam (not Transfer or Reciprocity) | 04/2024 |
LA-03 | Pharmacy Intern | 04/2024 |
LA-14 | Pharmacy Technician | 04/2024 |
LA-40 | Online Account Update Change in Name or Contact Info |
07/2018 |
LA-50 | Online Account Update Change in Employment |
07/2018 |
LA-55 | Change in Pharmacist License Status | 07/2018 |
LA-60 | Pharmacist - Reinstatement | 04/2024 |
LA-65 | Pharmacist - Reinstatement after Revocation | 04/2024 |
LA-70 | Technician - Reinstatement after Revocation | 04/2024 |
LA-75 | Technician Certification Extension Request | 08/2024 |
LA-80 | Duplicate Pocket Card | 07/2018 |
LA-85 | Duplicate Pharmacist Wall License | 07/2018 |
LA-100 | Pharmacist Original Wall License | 07/2018 |
Facility and Business Applications
Form # | Form Name | Revision Date |
---|---|---|
BA-02 | Pharmacy (Resident) | 06/2023 |
BA-04 | Manufacturer | 09/2022 |
BA-05 | Distributor (cs, prescription drugs, oxygen, & devices) | 09/2022 |
BA-06 | Nonprescription Drug Distributor | 12/2022 |
BA-07 | Research/Teaching Institution | 05/2022 |
BA-08 | Analytical Lab | 05/2022 |
BA-09 | Ambulance or EMS (in state) | 03/2022 |
BA-10 | Retail Dealer | 08/2023 |
BA-11 | Health Department or Clinic (in state) | 06/2023 |
BA-12 | Institutional Drug Room (in state) | 06/2023 |
BA-15 | Sample Drug Distributor | 03/2022 |
BA-16 | Durable Medical Equipment | 03/2022 |
BA-20 | Outsourcing Facility | 06/2023 |
BA-21 | Automated Drug Delivery System in LTCF | 06/2023 |
BA-22 | Non-Resident Pharmacy | 01/2022 |
BA-23 | Third-party Logistics Provider | 12/2022 |
BA-25 | Nonprescription Third-Party Logistics Provider | 12/2022 |
BA-50 | Change in PIC/PIC Resignation | 08/2024 |
BA-55 | Change in Designated Representative (or other) | 03/2020 |
BA-60 | BA-60 Facility Closure Notice | 09/2022 |
Supplemental Forms | ||
---|---|---|
S-100 | Background Check | Waiver for KBI/FBI background check and instructions for Fingerprint Card |
S-150 | Personal History | For individual applications with offense, disciplinary or criminal history |
S-200 | Continuing Education | For pharmacists submitting continuing education records as part of reinstatement or other application |
S-300 | Disciplinary History | For facilities reporting disciplinary history |
S-310 | Partnership Ownership | For facilities owned by a partnership or limited partnership |
S-320 | LLC Ownership | For facilities owned by an LLC |
S-330 | Corporate Ownership | For facilities owned by a public, private or nonprofit corporation |
S-340 | $25,000 Surety Bond Form | $25,000 surety bond form for wholesale distributors |
S-345 | $100,000 Surety Bond Form | $100,000 surety bond form for wholesale distributors |
S-350 | Non-Resident Supplement | For non-resident pharmacies, distributors, nonprescription drug distributors and DME |
S-400 | Intern Experience Hours | Log and preceptor certification for pharmacy intern experience hours |
S-500 | Kansas Hospital Electronic Supervision Form | For hospitals receiving remote supervision |
K-10 | Notice of Exemption from K-TRACS (PMP) Reporting | For pharmacies that do not dispense controlled substances |
N-100 | Automated Drug Delivery System Notice: Installation or Removal |
For a pharmacy, located and registered in Kansas, that will have an automated drug delivery system located in that pharmacy, institutional drug room or medical care facility For LTCF Automation, see BA-21 |
N-400 | Unused Medication Participation Form: Donating Entity | For medical care facilities, mail order pharmacies and adult care homes intending to participate in the Utilization of Unused Medications program by donating medications |
N-450 | Unused Medication Participation Form: Clinics & Qualifying Centers | For clinics and qualifying centers intending to participate in the Utilization of Unused Medications program by accepting medications |
Blank inspection forms are provided for general guidance to assist facilities in ensuring compliance with Board requirements. They are not intended to be an exhaustive list of all items that can or will be reviewed during a Board inspection.
The Board does not accept self-inspections.
INSPECTION FORMS |
|
---|---|
Pre-Opening Inspection | |
I-100 | Pre-Opening Inspection |
Pharmacy & Outsourcing Inspections | |
I-02P | Pharmacy Inspection |
I-02MCF | Medical Care Facility Inspection |
I-02ATC | Addiction or Treatment Center Inspection |
I-02C | Compounding Inspection Form |
I-20 | Outsourcing Facility Inspection |
DME & Retail Dealer Inspections | |
I-16 | Durable Medical Equipment Inspection |
I-10 | Retail Dealer Inspection |
Manufacturer, Distributor & 3PL Inspections | |
I-04 | Manufacturer Inspection |
I-05 | Distributor Inspection |
I-06 | Distributor Nonprescription Inspection |
I-23 | Third Party Logistics Inspection |
I-25 | Third Party Logistics Nonprescription Drugs Inspection |
Other Inspections |
|
I-07 | Research & Teaching Institution Inspection |
I-08 | Analytical Lab Inspection |
I-09 | Ambulance Inspection |
I-11 | County Health & Family Planning Inspection |
I-12 | Institutional Drug Room Inspection |
Non-Resident Self-Inspection Forms | |
NRI-06 | Nonprescription Drug/Device Distributor Self-Inspection |
NRI-22 | Nonresident Pharmacy Self-Inspection |
form # | form name |
---|---|
E-100 | Request CE Approval - Provider |
E-200 | Request CE Approval - Individual |
FORM # | FORM NAME |
---|---|
C-100 | Complaint Form |
C-200 | Transfer of Controlled Substances |
C-500 | CQI Meeting Report |
C-600 | Incident Report Form |
C-700 | ePrescribing Waiver Request Form |
C-800 | Open Records Request Form |
C-900 | Pharmacy Technician List |
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