PHARMACY MEMBERSHIP APPLICATION

Transcription

1 3 Parklane Blvd, Suite 1027 West Dearborn, MI Phone' Website PHARMACY MEMBERSHIP APPLICATION Dear Applicant: Thank you for your interest in becoming a member of the AAPA. In an effort for the Arab American Pharmacist Association and all of their members to maintain the highest level of integrity, ethical values, and professionalism please note that some changes have been made to our application process. FOR PHARMACY APPLICANTS ONLY. Complete the application below and submit the following documentation along with your application: 1. Articles of Organization and Assumed Name paperwork 2. Current copy of pharmacy's State & Controlled Substance License 3. Current copy of pharmacy's DEA certificate 4. Proof of Liability Insurance for the pharmacy 5. Photos of the pharmacy: a. Outside of the pharmacy, signage b. Drop off counter c. Pick-Up counter d. Counseling area PHARMACY LEGAL NAME PHARMACY D/B/A OR TRADE NAME PHARMACY ADDRESS CITY STATE ZIP CODE COUNTY PHARMACY PHONE PHARMACY FAX New Location Yes I No Expected Opening Date Type of Pharmacy Retail/Community 1 Long Term Care Close Door Pharmacy OWNERS/CORPORATE OFFICERS 1. FULL NAME NATIONAL ORIGIN/ETHNICITY PHARMACIST LICENSE # Owner 1/President: Owner 2/Shareholder: Owner 3/Shareholder: Page 1 of 5

2 3 Parklane Blvd, Suite 1027 West Dearborn, MI Phone I Website 2. Is at least 15% of the pharmacy's stock owned by a Pharmacist licensed in the United States? Yes No 3. Has any owner, employee or stockholder ever been convicted of a misdemeanor or a felony? Yes "No 4. Has any owner, employee or stockholder ever been financially vested in another healthcare company which has had a Healthcare License denied, revoked, or been subject to any civil, criminal or administration penalty? Yes No 5. Has any Pharmacist owner or employee of this organization ever had a license denied, suspended, revoked? Yes No (If you answered "yes" to any of the questions above please attach an explanation of the offense) OWNER CONTACT INFORMATION 6. Owner's Full Name Home Address Direct Number 7. Do you own other pharmacies that are AAPA members? If so, please provide the name & full address below if you own more than two locations. (Attach a separate sheet if necessary) PHARMACY NAME PHARMACY ADDRESS 8. Person we may contact if we have questions about this application Direct Number 9. PHARMACIST-IN-CHARGE (FIRST & LAST NAME, DEGREE) LICENSE NUMBER PHARMACY INFORMATION 10. Pharmacy status? New Existing If Existing, how many years open: 11. Are there any other independent pharmacies within a mile of your location? 12. Who is your pharmacy's Primary Drug Wholesaler? 13. How did you hear about the AAPA? 14. Briefly list your expectations for joining the AAPA: Page 2 of 5

3 3 Parklane Blvd, Suite 1027 West Dearborn, MI Phone I Website I acknowledge that all statements in this application are complete and accurate to the best of my ability. Applicant Signature Date Print Name Page 3 of 5

4 3 Parklane Blvd, Suite 1027 West Dearborn, MI Phone I Website PHARMACIST CODE OF ETHICS Pharmacists are health professionals who assist individuals in making the best use of medications. These principles, based on moral obligations and virtues, are established to guide pharmacists in relationships with patients, health professionals and society. A pharmacist respects the covenantal relationship between the patient and pharmacist. Considering the patient-pharmacist relationship as a covenant means that a pharmacist has moral obligations in response to the gift of trust received from society. In return for this gift, a pharmacist promises to help individuals achieve optimum benefit from their medications, to be committed to their welfare, and to maintain their trust. A pharmacist promotes the good of every patient in a caring, compassionate and confidential manner. A pharmacist places concern for the well-being of the patient at the center of professional practice. In doing so, a pharmacist considers needs stated by the patient as well as those defined by health science. A pharmacist is dedicated to protecting the dignity of the patient. With a caring attitude and a compassionate spirit, a pharmacist focuses on serving the patient in a private and confidential manner. A pharmacist respects the autonomy and dignity of each patient. A pharmacist promotes the right of self-determination and recognizes individual self-worth by encouraging patients to participate in decisions about their health. A pharmacist communicates with patients in terms that are understandable. In all cases, a pharmacist respects personal and cultural differences among patients. A pharmacist acts with honesty and integrity in professional relationships. A pharmacist has a duty to tell the truth and to act with conviction of conscience. A pharmacist avoids discriminatory practices, behavior or work conditions that impair professional judgment, and actions that compromise dedication to the best interests of patients. A pharmacist maintains professional competence. A Pharmacist has a duty to maintain knowledge and abilities as new medications, devices and technologies become available and as health information advances. A pharmacist respects the values and abilities of colleagues and other health professionals. When appropriate, a pharmacist asks for the consultation of colleagues or other health professionals or refers the patient. A pharmacist acknowledges that colleagues and other health professionals may differ in the beliefs and values they apply to the care of the patient. A pharmacist serves individual, community and societal needs. The primary obligation of a pharmacist is to individual patients. However, the obligations of a pharmacist may at times extend beyond the individual to the community and society. In these situations, a pharmacist recognizes the responsibilities that accompany these obligations and acts accordingly. A pharmacist seeks justice in the distribution of health resources. When health resources are allocated, a pharmacist is fair and equitable, balancing the needs of patients and society. Page 4 of 5

5 3 Parklane Blvd, Suite 1027 West Dearborn, MI Phone' Website AAPA MEMBER CODE OF CONDUCT AGREEMENT OF COMMITMENT The Arab American Pharmacists Association (AAPA) strives to advance and support Arab American Pharmacists in serving society as the profession responsible for the appropriate use of medications and services to enhance optimal patient care and public health. The AAPA is the leading voice of Arab Pharmacist through advocacy, education, and information dissemination. With the combined power of our member pharmacies we are able to bring you a multitude of benefits and discounts that will increase your effectiveness in your profession. Yet, in order to continue to provide these benefits and services, all active members must act according to the laws and regulations governing the profession and adhere to the code of Ethics of the Michigan Pharmacists Association, attached to this agreement and to the constitution and bylaws of the AAPA. A Member Pharmacist has the duty to observe the law, to uphold the dignity and honor of the profession, and to accept its ethical principles. A Member Pharmacist should not engage in any activity that will bring discredit to the profession. Society holds pharmacists to a high degree of duty, integrity and honor, reflecting a responsibility to their patients and their community. As developing professionals, it is the responsibility of Member Pharmacist to uphold these high expectations and to conduct themselves accordingly by observing all applicable federal, state, and local laws, as well as institutional policies, regulations and guidelines. Members are required to sign this agreement of commitment as a condition of membership. I have read, and hereby agree to abide by the Constitutions, Bylaws and Code of Ethics of the AAPA: Print Member Name: Name of Pharmacy: Member Signature: Date: Witness: Page 5 of 5