Dispenser Waiver Application

Apply for exemption from Illinois RxSubmit data reporting requirements

TODAY'S DATE

Step 1 of 3 Dispenser Information

Step 2 of 3 Reason for Waiver

Step 3 of 3 Affirmation & Signature

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01 · 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 *

I attest the pharmacy does NOT hold a Drug Enforcement Administration (DEA) License Number

Pharmacy / Dispenser DEA Number *

Pharmacies with a DEA License Number must include it on this waiver application.

02 · Reason for Waiver Request

This application is for an exemption from submitting data as required by the Illinois Controlled Substance Act and applicable rules.

Dispenser does not dispense ANY Controlled Substances II, III, IV, and V or drugs of interest to Illinois Residents.

Drugs of interest include: all butalbital combination products, gabapentin, muscle relaxants, and opioid antagonists.

Dispenser does not dispense any Long Term Care Appendix A drugs to Illinois Residents residing in Long Term Care facilities. Long Term Care Appendix A drugs found here.

Dispenser only dispenses the exempt Controlled Substances listed in Public Act 104-0535 (b) found here.

03 · Affirmation

This waiver is to be completed on an annual basis and is valid until June 30th of the following year.

A dispenser who begins dispensing ANY controlled substances II, III, IV and V or drugs of interest to Illinois Residents rescinds this waiver and shall begin submitting daily reports.

Contact DHS.DBHR.PharmacyCompliance@illinois.gov for further assistance.

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

Signature *

Title *

Date *

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