Step2: Questionnaire
1. What Percentage of your business performs the following? Please note, 1A and 1B are separate line items and each line item should equal to 100%.
1A. Source of Revenue: The Four Boxes Below Should Total A Combined 100%
Walk-In/Appointment
Phone/Fax-in
Mail Order
Internet

The 4 fields value should be in positive

The sum of above 4 fields should be equal to 100%


1B. Types of Revenue: The Two Boxes Below Should Total A Combined 100%
Cash
Insurance

The 2 fields value should be in positive

The sum of above 2 fields should be equal to 100%


2. What percent of the pharmacy prescription business is controlled substances?

Enter valid input


3. What percent of prescriptions for controlled substances come from pain management clinics?

Enter valid input


4. How many total prescriptions are filled monthly?

Select at least one


Review The Following Statements
5. Has the owner or facility ever had a DEA registration suspended or revoked?

Enter valid input


6. Does the facility solicit buyers or orders of controlled substance via the internet or offer to facilitate the acquisition of a prescription for a controlled substance from a practitioner with whom the buyer has no pre-existing relationship via an online questionnaire without a medical examination or bona-fide doctor-patient relationship?

Enter valid input


7. Does your facility have a website?

Enter valid input

Maximum 100 characters allowed.


8. Is your clinic or facility affiliated with another pharmacy?

Enter valid input


9. Are one or more practitioners writing a disproportionate share of the prescriptions for controlled substances being filled by the pharmacy?

Enter valid input


10. Does the pharmacy offer to sell controlled substances without a prescription?

Enter valid input


11. Any exceptions / circumstances where the pharmacy does not follow procedures to verify prescriptions and validate bona-fide doctor-patient relationship?

Enter valid input


12. Any exceptions / circumstances where the polices and procedures set by the pharmacy/clinic to prevent the diversion of any medication by staff employees / patients / other are not used?

Enter valid input


13. Does the pharmacy / clinic fill prescriptions for patients who are not domiciled in the state they are located in?

Enter valid input


14. Have any corporate Officer/Owner/Pharmacist of the pharmacy ever been charged, convicted, plead no contest or had adjudication withheld on any charge involving possession, use or distribution of controlled substances Act or any state laws pertaining to controlled substances?

Enter valid input


List the names of authorized signers of DEA Form 222 or holders of CSOS certificates (C.F.R 1205.05)

Required.

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