Healthcare Pharmacy Manager Form

HEALTHCARE PHARMACY MANAGER FORM

Pharmacy Name:   State Pharmacy License No.:

DEA Registration No.:   DEA Expiration:

PHARMACY MANAGER / PHARMACIST-IN-CHARGE

Full legal name:

Pharmacist License No.:   State of License:   License Expiration:

Business phone:   Personal phone:   Email:

DESIGNATION AND EFFECTIVE DATES

Effective date of designation:

Term of designation (if applicable):

RESPONSIBILITIES AND ATTESTATION

The undersigned accepts designation as Pharmacy Manager / Pharmacist-in-Charge and acknowledges responsibility for compliance with applicable laws, regulations, and standards governing the operation of the pharmacy, including but not limited to the safe procurement, storage, dispensing, and recordkeeping of controlled substances and legend drugs. The Pharmacy Manager affirms that the duties listed below will be performed in accordance with prevailing law and established pharmacy policies.

Select duties assumed (check all that apply):

I accept responsibility for establishing and maintaining perpetual and physical inventory procedures and completing required inventories for controlled substances.

I will supervise pharmacy staff and ensure that all dispensing, labeling, and counseling activities comply with law and pharmacy policy.

I will ensure accurate recordkeeping, retention, and retrieval of prescription records, controlled substance logs, and related documentation.

I will report suspected diversion, loss, or theft of drugs in accordance with legal and organizational reporting requirements.

I will develop, maintain, and enforce written pharmacy policies and procedures, including controlled substance security and handling.

I will oversee staff training and competency assessments and ensure compliance with continuing education and license renewal requirements.

Inventory audit frequency (e.g., monthly, quarterly):   Primary inventory custodian:

CONFIDENTIALITY AND PRIVACY

The Pharmacy Manager affirms responsibility for safeguarding protected health information and maintaining patient confidentiality in accordance with applicable privacy laws and organizational privacy policies. Access to patient records and electronic systems will be limited to authorized personnel and monitored for compliance.

I acknowledge receipt of and compliance with the pharmacy's privacy and confidentiality policies.

DELEGATION, ACCESS, AND SYSTEMS

The Pharmacy Manager may delegate certain operational tasks to qualified staff but retains ultimate responsibility for delegated functions. The Pharmacy Manager is authorized to request or revoke access to dispensing systems and controlled substance records as necessary to carry out oversight responsibilities.

LOSS, DIVERSION, INCIDENT REPORTING

The Pharmacy Manager will ensure prompt internal and, where required by law, external reporting of all incidents involving loss, suspected diversion, tampering, or theft of pharmaceutical products. The Pharmacy Manager will cooperate with investigations and corrective actions.

Primary reporting contact name:   Contact phone:

EMERGENCY CONTACT

Emergency contact name:

Relationship:   Phone:

ADDITIONAL INFORMATION

Certification: By signing below, I certify that the information provided is true and correct to the best of my knowledge, that I accept the duties and responsibilities described in this form, and that I understand that failure to comply with applicable laws and pharmacy policies may result in disciplinary action, revocation of designation, or reporting to licensing authorities as required.

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