Apply for Accreditation (Long-Term Care @ Home Pharmacy) Thank you for choosing BOC for your facility accreditation. Download Application Apply For Accreditation - LTC@Home Pharmacy Long-Term Care @ Home Pharmacy Form Application * Indicates required entry Facility Name * Doing Business As (DBA) Number of Years in Business Corporate Name * Pharmacy URL * Facility Street Address * Suite Number City * State * Zip Code * Country * Facility Phone Number * Telephone Number * LTC NPI/NCPDP Contact Email * Business Email * Secondary Email Posted Business Hours (For every day, please indicate AM/PM and if the facility closes for lunch) Monday Closed Closed Open Time Closed Time Closed For Lunch? Closed Lunch Start Lunch End Tuesday Closed Closed Open Time Closed Time Closed For Lunch? Closed Lunch Start Lunch End Number Wednesday Closed Closed Open Time Closed Time Closed For Lunch? Closed Lunch Start Lunch End Thursday Closed Closed Open Time Closed Time Closed For Lunch? Closed Lunch Start Lunch End Friday Closed Closed Open Time Closed Time Closed For Lunch? Closed Lunch Start Lunch End Saturday Closed Closed Open Time Closed Time Closed For Lunch? Closed Lunch Start Lunch End Sunday Closed Closed Open Time Closed Time Closed For Lunch? Closed Lunch Start Lunch End Credential Personnel (Please include additional practitioners on an attached document) Head Pharmacist Name * License # Mobile Number Fax Number National Provider Identifier # (NPI) Pharmacy License Number/Expiration Date DEA Registration Number/Expiration Date Retail NPI/NCPDP, if applicable PIC Information and License Number Accreditation and Certification Information Is your facility currently accredited? * YesNo If yes, by which accrediting organization? If yes what is your facility accredited for? CMS Provider # (PTAN) Medicare Billing Number, if applicable Medicaid Provider Number, if applicable Compliance and Packaging Information Type of Compliance Packaging Officers and Ownership Information Owner(s) * Compliance Officer * Corporate Officer(s) Third Party Consultant Information How did you hear about BOC? * BOC Website LTC@HQC Internet Social Media Colleague Trade Show Did you use a Third Party Consultant? YesNo Third Party Counsultant Name Third Party Counsultant Email Did you work with a BOC Business Development Representative? YesNo Name of Representative Owner/Corporate Officer Signature In signing this affidavit, I attest, upon personal knowledge, that all information reported in this application, including any and all accompanying documentation, is complete, accurate and true, to the best of my knowledge. I understand that falsification of information may result in a denial or revocation of accreditation. I agree to notify BOC in writing of all changes to ownership, corporate structure, location, or provision of services/equipment. In submitting this application, I understand that I am granting permission to BOC and its authorized representatives to inspect my facility during normal business hours and without prior notification. Type your name as your Electronic Signature: * Date (00/00/0000) * Facility Accreditation Fees Fees LTC@Home Pharmacy Survey and 2-Year Accreditation: $7,995 Total Payment Method Payment Type Credit Card PaymentCheck Payment Card Type VisaMasterCardDiscoverAmerican Express Credit Card Number Credit Card Number Credit Card Number Credit Card Number Expiration Month 123456789101112 Credit Card Number Expiration Year 20242025202620272028202920302031203220332034 Credit Card Number Name As It Appears On Card Cardholder Signature (Type your name as your electronic signature) Checkboxes Check Enclosed Check Number Billing Address Billing Address Billing Address Billing Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal The issuer of the card identified on this form is authorized to pay the amount shown as Payment Amount upon proper presentation. I agree to pay such Payment Amount (together with any other charges due thereon) subject to and in accordance with the Agreement governing the use of such card. Make Check or Money Order payable to BOC. If your check is returned for any reason, you must submit a bank draft, money order, or credit card payment with an additional fee of $35.00 to cover the returned check processing fee. Applications from outside of the contiguous United States will be subject to a surcharge for additional travel expenses. BOC does not offer refunds or accept post-dated checks. An additional Site Survey fee of $995.00 may be compulsory under specific circumstances. Under these circumstances the facilities will be made aware of this prior to the survey taking place. Notwithstanding anything to the contrary contained herein, to the maximum extent permitted by applicable law, except in the instance of willful misconduct or gross negligence of BOC (or any of its employees, agents, or contractors (“Related Parties”)), the maximum aggregate liability of BOC arising out of or in connection with this Accreditation Application (including any inspection or audit of Applicant’s facility) shall not exceed the aggregate amount paid or payable by Applicant to BOC for the Application fee and all services, including any inspection or audit, giving rise to such liability, as of the date of the events or circumstances giving rise to such liability. Submit If you are human, leave this field blank.