Kansas Prescription Drug Monitoring Program
800 SW Jackson, Suite 1414
Topeka, Kansas 66612-1244
Ph: (785) 296-6547 Fax (785) 296-8420
Please submit form to: [email protected]
K-TRACS
Request for Exemption
from Reporting
Form K-10
Page 1 of 2 Revised 04/24
INSTRUCTIONS
Please use the online exemption request form for initial exemption requests and annual renewals. Use this form when satisfying the requirements of
the BA-50 to recertify an exemption following a change in Pharmacist in Charge. All forms must be typed, be complete, and include all supporting
documentation before they will be processed. This form must be signed by the Pharmacist in Charge. Dispensers must continue reporting to K-
TRACS while waiting on a determination of exempt status.
DISPENSER INFORMATION
Name
Kansas Registration Number (if assigned)
Address
Phone
City
State
Zip
Email
DEA Number
A. EXEMPTION FROM ALL REPORTING REQUIREMENTS
This exemption all
ows dispensers to waive all reporting requirements described in K.A.R. 68-21-2. (skip if applying for Section B exemption)
INDICATE REASON FOR EXEMPTION (check all that apply)
Dispenser is a licensed hospital pharmacy that distributes scheduled substances and drugs of concern for the purposes of inpatient hospital care
only. Please note that K.A.R. 68-21-2 also exempts reporting of interim supplies of 48 hours or less.
Dispenser is a medical care facility, practitioner or other authorized person who only administers scheduled substances and drugs of concern to
patients.
Dispenser does not dispense scheduled substances or drugs of concern in the state of Kansas or to an address in this state. Please answer the
following questions:
Yes No Have you submitted at least 3 months’ worth of dispensations and/or zero reports to Kansas or attached a copy of your
dispensing records for the past 3 months?
Nonresident Pharmacies Only:
Yes No Is your pharmacy registered in other states? If yes, please provide a list.
Yes No Are you exempt from PDMP reporting requirements in any of those states? If yes, please provide a list.
Yes No Have you received any written reprimand, censure or other disciplinary action related to PDMP reporting in
other states? If yes, please provide a copy of each.
B. EXEMPTION FROM ZERO REPORTING REQUIREMENTS (skip if applying for Section A exemption)
This exemption allows dispensers to waive the requirement to zero report for days in which no dispensations occur. Dispensers still must report all
dispensations of scheduled substances and drugs of concern within 24 hours of dispensation (K.A.R. 68-21-2). Dispenser must meet both criteria
listed below to qualify for an exemption.
INDICATE REASON FOR WAIVER
Dispenser has a volume of scheduled substances and drugs of concern that does not exceed 10 prescriptions sold per month
Dispenser does not have the ability to automate zero report submissions
COMMENTS
Please provide any comments related to your exemption request that the state should consider.
See page 2 for additional details >>
Page 2 of 2
Revised 05/23
CERTIFICATION
I certify under penalty of perjury under the laws of the State of Kansas that the information provided on this form, including supporting
documentation, is true and correct and that the above-named dispenser is licensed/registered to practice in the State of Kansas. I understand that it
is the responsibility of the prescriber or dispenser named above to notify the Board immediately if (1) there is a change in the dispensing status
stated above or (2) the dispenser or prescriber named above begins dispensing scheduled substances or drugs of concern in Kansas or to an
address in Kansas.
SIGNATURE OF PHARMACIST IN CHARGE
DATE SIGNED
PRINTED NAME
OFFICE USE ONLY
Approved Denied Initials: Date:
