Pharmacy Information
These sample forms are intended to assist EMS services as they implement the November 09, 2011 revisions to 657-Chapter 11 (124.1, 147A, 155A) Drugs in Emergency Medical Service Programs.
Agreement Options
Services may select from sample pharmacy-based, medical-director-based or combination pharmacy-based and medical-director based options. Services that select the combination option will submit each a pharmacy-based and a medical-director based agreement that clearly defines the ownership of specific drugs.
Sample Agreements and Forms
No Controlled Substances (CS) - Sample agreements and forms for services that carry Epi-pens and/or IV fluids or other prescription drugs, but do not carry controlled substances:
- Pharmacy-based option agreement - Epi-pen or IV fluids only, NO CS
- Medical director-based option agreement - Epi-pen or IV fluids only, NO CS
- Drug Inspection Record - Epi-pen or IV fluids only, NO CS
- Drug Replenishment Form - Epi-pen or IV fluids only, NO CS
With Controlled Substances (CS) - Sample agreements and forms for services that carry prescription drugs including controlled substances:
- Pharmacy-based option agreement - WITH CS
- Medical director-based option agreement - WITH CS
- Controlled Substance Tracking Form - WITH CS
- Drug Replenishment Form - WITH CS
- Perpetual Inventory Log - WITH CS
With or Without Controlled Substances - Sample forms that may be helpful for services that do or do not carry controlled substances:
- Pharmacy Signature Log
- Drug Security Log and Inspection Record
- Receipt and Disbursement Tracking Form
- Pharmacy Incident Report
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