Discipline/State or Federal Action Reporting Form

Effective August 28, 2016, Board licensees, registrants and permit holder are required to report to the Board:

  1. Any final adverse action taken by another licensing state, jurisdiction or governmental agency against any license to practice or operate as a pharmacist, intern pharmacist, pharmacy technician, pharmacy, drug distributor, drug manufacturer or drug outsourcing facility;
  2. Any surrender of a license or authorization to practice as a pharmacist, pharmacy, drug distributor, technician, intern pharmacist or drug outsourcer; and
  3. Any exclusion to participate in any state or federal funded health care program such as Medicare, Medicaid or MoHealthNet for fraud or abuse or for submitting any false/fraudulent claim for payment or reimbursement.

COMPLETE THE FORM BELOW TO FILE AN ONLINE REPORT

You must fill out all required fields.

Please forward copies of any disciplinary, exclusion or voluntary surrender documents to the Board office or e-mail them to: Tom.Glenski@pr.mo.gov.