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 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.

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: