2020 - VPMS Exemption Form for Vermont Licensed Pharmacies

Vermont Prescription Monitoring Program
Division of Alcohol and Drug Abuse Programs
P.O. Box 70, 108 Cherry Street, Suite 2
Burlington, Vermont 05402-0070
Telephone: 802-652-4147
Fax: 802-652-2019
Email: AHS.VDHVPMS@vermont.gov

VPMS Exemption Form for Vermont Licensed Pharmacies

Pharmacy Name *This question is required.

Street Address *This question is required.

Apt/Suite/Office

City *This question is required.

State *This question is required.

Zip *This question is required.

Phone Number *This question is required. This question requires a valid number format.

Vermont Pharmacy License Number *This question is required.

Pharmacy DEA Number *This question is required.

2. I certify that this pharmacy currently: (select one) *This question is required.

Should this situation change, I understand that we need to contact the VPMS Program Manager (ahs.vdhvpms@vermont.gov) and begin making reports of controlled substances dispensed to the Vermont Prescription Monitoring System which shall be no less than once every 24 hours or one (1) business day. I understand that the exemption will need to be renewed annually during the exemption registration period which is January 1st through January 31st.

3. Date *This question is required. This question requires a valid date format of MM/DD/YYYY.

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4. Pharmacist Manager email address *This question is required. This question requires a valid email address.

5. PDMP Exemption Compliance Contact Email *This question is required. This contact will be notified when the exemption form is due to be renewed. This question requires a valid email address.

6. Pharmacist Manager Signature *This question is required.

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Signature of