Illinois RxSubmit Application

APPLICATION REQUEST FOR WAIVER OF REPORTING REQUIREMENTS FOR Illinois RxSubmit

Today's Date: {{todaysDate}}

DISPENSER INFORMATION
*Required Fields
*Name of Pharmacy/Dispenser:
*IL Pharmacy license number or Prescriber license number:	NPI Number:
*Street Address:	*Email Address:
*State:	*City:
*Zip Code:	*Phone Number:
*Pharmacy/Dispenser DEA Number:

REASON FOR WAIVER REQUEST:

This application is for an exemption from submitting data as required by the Illinois PMP.

Dispenser is a medical facility that dispenses an interim quantity of a substance on an outpatient emergency basis; the quantity does not exceed a 72-hour supply.

Pharmacy or Prescriber does not dispense ANY controlled substances II, III, IV and V or drugs of interest in the state of Illinois.

AFFIRMATION

By signing below, I certify that all statements contained in this waiver application are true and correct.

Signature: Title: Date: