Florida Health Care Clinic Establishment (HCCE) form

MWI Account number*

Practice or DVM Name*

Phone Number*

I would like to:

Submit my updated credentialsRequest an exemption to this requirement (available potential exemption reasons specified on form)Submit an existing exemption

Credentials File Upload*

Existing Exemption File Upload*

Under Florida law, in section 499.01(2)(r) a Health Care Clinic Establishment (HCCE) permit is required for the purchase of a prescription drug by a place of business at one general physical location that provides health care or veterinary services, which is owned and operated by a business entity that has been issued a federal employer tax identification number. This requirement may apply to you if you are a practice or clinic that operates as a separate legal entity such as a Corporation, LLC, PA, etc. with its own federal employer tax identification number.

The HCCE permit requirement does not affect the ability of a veterinarian, either individually or through the veterinarian’s sole proprietorship, to purchase drugs under his or her own name and veterinary license number, without the need for an HCCE permit. In addition, we believe that the Florida Department of Health has clarified that a veterinarian in a group practice or clinic who wants to order prescription drugs in his or her own name and license number, for use at the practice or clinic, may do so without an HCCE Permit, if the veterinarian clearly specifies his or her intention of purchasing the drugs under the authority of his or her license and acknowledges responsibility for the drugs. The veterinarian may also provide billing directions, and any invoices and shipping documents must reflect the name and license number of the veterinarian to whom the drugs are sold. The following declaration has been created to confirm the intention of any veterinarian who wishes to purchase drugs under this scenario.

To Claim Exemption from the HCCE permit requirement, at least one of the following must be checked. This form will not be accepted without providing a reason for exemption and a signature.

I, the undersigned, am exempt from the requirement to obtain an HCCE permit due to the following reason.*

I am an individual practitioner and products are purchased for my own use, and for my personal account, and not paid for with business funds.I am a solo practitioner with a professional business entity (PLLC or PA). Products are ordered under my individual veterinarian license but paid for with business funds.I am a government animal shelter and all employees of the shelter are employed by the local government.I am a non-government animal shelter and have provided a copy of an exemption letter issued by the Florida Division of Drugs Devices and Cosmetics.I have an exemption letter issued by the Florida Division of Drugs Devices and Cosmetics which is enclosed with the exemption form.I own a mobile veterinary clinic and do not have a permanent location (apermanent location does not include a personal residence).I operate solely as a ‘house call’ veterinarian.

Veterinarian's name*

Practice name*

Account number*

Veterinarian's license address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

1. I have the authority pursuant to applicable law to order, purchase, and store prescription drugs under the authority of my:

State of Florida license number*

2. All prescription drugs ordered from MWI Animal Health shipped to (name of the entity) located at (ship to address) are being purchased by me and under the authority of my license.

Name of entity*

Ship to address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

3. I have directed MWI Animal Health to remit bills for any such drugs purchased to (billing name and address)

Billing name*

Billing address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

4. I will be responsible in all respects for the receipt, recordkeeping, storage and handling of any prescription drugs purchased under the authority of my license.

5. I will notify MWI Animal Health of any changes to the license on this account or if any of the above statements is no longer true.

Signature*

Date*

I HEREBY CERTIFY that the information provided in this form is complete, true and correct.

Florida Health Care Clinic Establishment (HCCE) form

Exemption Requests

Declaration of intention