TX HHS Form 1061. Class D Pharmacy License Exemption Request

The TX HHS Form 1061, Class D Pharmacy License Exemption Request, is a crucial document for healthcare providers seeking to exempt themselves from obtaining a Class D pharmacy license. This form helps solve the problem of streamlining pharmaceutical services for eligible individuals by allowing clinics to partner with referral pharmacies and provide medications without an additional clinic visit.

The form requires agency/clinic information, including name and location, as well as a brief description of the pharmacy referral process. Key features include the elimination of barriers to medication access, ensuring that individuals do not incur additional costs, and coordination between the agency/clinic and referral pharmacies. Additionally, the form includes a Memorandum of Understanding (MOU) with the referral pharmacy/pharmacies, outlining the purpose of cooperation and procedures for providing specific medications.

To complete this form, authorized representatives of healthcare agencies or clinics must provide justification for requesting a Class D pharmacy license exemption, including benefits to the agency and/or individuals. The form also requires a copy of the agency's/clinic's policy ensuring that eligible individuals can obtain prescribed medication refills from cooperating pharmacies without an additional clinic visit (unless medically indicated). Key points to note include:

• Partnership between agencies/clincs and referral pharmacies
• Elimination of barriers to medication access
• Coordination between parties for providing specific medications
• Justification for requesting a Class D pharmacy license exemption