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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

Licensee Information
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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.